Behavior Today Newsletter 42.2

Girls with Autism, Social Anxiety, and the Relationship to Eating Disorders as Restrictive, Repetitive Behaviors

Doris Hill

The ratio of boys to girls with autism spectrum disorder (ASD) diagnoses has historically been seen as 4:1. Recent research notes the ratio may be closer to 2:1 since most normed research was conducted with boys, and girls may present differently, resulting in male bias. Girls whose presentation is similar to males (e.g., with behavior issues) are more likely to be diagnosed.  Girls who are not diagnosed in a timely manner do not benefit from interventions and other services available (Gray et al., 2021).

Flaherty (2002) cited reasons why girls are less likely to be identified when placed in a general education setting.  She noted girls often have more internalizing personalities and are less likely to outwardly express their challenges. Boys pose more of a disruption in the classroom since they demonstrate more externalizing behaviors. Girls are more likely to have socially acceptable perseverations (similar to neurotypical girls but with greater intensity). Girls tend to be overlooked unless they have significant behavior difficulties, cognitive deficits, or have other conditions that may be disruptive to their environment. Girls who make little eye contact are often seen as shy.

Consequences of delayed diagnosis of ASD in females may include social isolation, peer rejection, lowered grades, and greater risk for mental health and behavioral distress as well as a lack of access to services and interventions (Aspy, 2024; Gray et al., 2021). Having the diagnosis and the support it brings can have a major impact in lowering anxiety and depression levels (Lewis, 2017).

In a United Kingdom study, Gray et al., (2021) examined parental views as well as those from Special Education (SPED) coordinators. Results indicated that SPED coordinators have a better understanding of male presentation of ASD.  They were less confident about identifying and supporting girls.

O’Connor et al. (2024) examined 52 eligible studies that studied the unique perspectives of adolescent autistic girls and adults at a University in Dublin, Ireland.  They conceptualized three areas in a social model to address these perspectives.  They titled them “the autism neurotype” (psychological and biological factors), social factors (the neurotypical world and stigma). These impact well-being and mental health outcomes. They suggest using visual supports, public spaces designed to address sensory stimuli, autism acceptance training and anti-stigma campaigns. As the literature has shown, girls are diagnosed later than boys which impacts the supports they receive. This gender bias is becoming more acknowledged in the literature, but a study in the United Kingdom found that standard autism assessment tools such as the Autism Diagnostic Observation Schedule-2 (ADOS-2) don’t reflect this discrepancy (ADOS-2, 2012; Gray et al., 2021). For some school staff members, there is a belief that behavioral difficulties must exist for an individual to be classified as autistic.

Also, parents of girls with autism often see the need for services, which can differ with the opinion of those of the school. School professionals sometime dismiss the need entirely if there are no behaviors that impact learning (Jarman & Rayner, 2015). A study by Sharpley and Bitska (2022) examined the association between self-reported social anxiety and eating disturbances in girls with autism between the ages of six and fourteen. They posit that pressure of girls to be social and the tendency to mask autism symptoms increases their self-reported social anxiety and eating disturbances (which are seen as restrictive and repetitive behaviors) in girls.

As noted in this article, research in both the UK and USA shows that girls are significantly less likely to be diagnosed with autism spectrum characteristics than male peers with similar levels of autism spectrum traits (Baldwin & Costley 2015; Cheslack-Postava & Jordan-Young 2012).

An awareness of this disparity in evaluation as well as professional training and proactive identification for evaluation and diagnosis can help girls and women with ASD access the supports they need.

References

Aspy, R. (2024). Girls on the autism spectrum. Ohio Center for Low Incidence Disabilities. https://autisminternetmodules.org/m/523

Lord, C., Rutter, M. DiLavore, P. C., Risi, S., Gotham, K., Bishop, S. L., Luyster, R. J., & Guthrie, W. (2012). Autism Diagnostic Observation Schedule (2nd edition). Western Psychological Services.

Baldwin, S., & Costley, D. (2015). The experiences and needs of female adults with high-functioning autism spectrum disorder. Autism, 20(4), 1-13. doi: 10.1177/1362361315590805  

Cheslack-Postava, K., & Jordan-Young, R. M. (2012). Autism spectrum disorders: Toward a gendered embodiment model. Social Science and Medicine, 74(11), 1667–1674.

Flaherty (2002). Asperger’s syndrome in women:  A different set of challenges? In Anita Lesko (Ed.) Autism in Girls (pp 1-16), Future Horizons.

Gray, L., Bownas, E., Hicks, L., Hutcheson-Galbraith, E., & Harrison, S. (2021). Towards a better understanding of girls on the autism spectrum: Educational support and parental perspectives. Educational Psychology in Practice, 37(1), 74-93.

Jarman, B., & Rayner, C. (2015). Asperger’s and girls: What teachers need to know. Australasian Journal of Special Education, 39(2), 128-142. https://doi.org/10.1017/jse.2015.7

Lewis, L. F. (2017). A mixed-method study of barriers to formal diagnosis of autism spectrum disorder in adults. Journal of Autism and Developmental Disorders, 47(8), 2410-2424.

O’Connor, R. A. G., Doherty, M., Ryan-Enright, T., Gaynor, K. (2024). Perspectives of autistic adolescent girls and women on the determinants of their mental health, and social and emotional well-being: A systematic review and thematic synthesis of lived experience. Autism, 28(4), 816-830. doi:10.1177/13623613231215026

Sharpley, C., & Bitsika, V. (2022). The association between self-rated social anxiety, social functioning, and eating disorders in girls with autism spectrum disorder. International Journal of Disability, Development, and Education, 69(2), 657-671. https://doi.org/10.1080/1034912x.2020.1731435.

My Most Memorable Student: Voices from the Field – Lyndal Bullock*

Jim Teagarden & Robert Zabel, Kansas State University

The Janus Oral History Project, sponsored by the Midwest Symposium for Leadership in Behavior Disorders (MSLBD), collects and shares stories from leaders in education of children with emotional and behavioral disorders (EBD). The Project is named after the Roman god, Janus, whose two faces look simultaneously to the past and future.

One Janus Project activity is recording educators’ descriptions of memorable students. They are asked: Who is your most memorable student? What did you learn from this student? How has the student impacted your career or life? What follows is Dr.  Lyndal Bullock’s account of how a student taught him a fundamental truth.

*****

When you’ve been in the business as long as I have there are many, many memorable students. There is this one that I brag about. It was in my second year of teaching, the first year I was there I had this class of incredible students. Most of them weren’t labeled as special ed but back in those days they weren’t labeled so much. The second year I was supposed to have the same group of kids but in the wisdom of the school district they changed classes. When I announced to the group, they would be in a different class next year this little gal started to leave the room. Then she grabbed me and said, “Oh, Mr. Bullock I don’t know how I’ll live without you.” 

What that really told me was, for these kids what is really important is trust and knowing they can depend on you. They need to know you are there to support, and that’s been a fundamental thought in my mind over the years.

* * * * *

Lyndal Bullock’s story is a part of the MSLBD video series, “My Most Memorable Student.” You can view Dr. Bullock telling his story at Lyndal's story and more than 40 stories of other memorable students at: http://mslbd.org/what-we-do/educator-stories.html. In addition, Dr. Bullock’s Janus Oral History Project interview can be viewed at Lyndal's interview and is also available in print (Zabel, Kaff, & Teagarden, 2018).

*Dr. Lyndal Bullock is Distinguished Professor of Special Education Emeritus at the University of North Texas. Dr. Bullock has served in many professional leadership roles, including President of both Council for Exceptional Children (CEC) and Council for Children with Behavior Disorders (now Division for Children’s Mental Health).

Reference

Zabel, R., Kaff, M., & Teagarden, J. (2018). The call of a different drummer: A Conversation with Lyndal Bullock. Intervention in School and Clinic, 53(3), 193-196.

Theo’s Day in ABA Dimensions

Eric Alan Common, Ph.D., BCBA-D, University of Michigan-Flint

A deep understanding of behavior and behaviorism, along with core competencies in education and child development, is critical in addressing students' behaviors of concern and supporting their academic, behavioral, and social-emotional learning needs more broadly. In applied behavior analysis, Baer et al. (1968) proposed a set of dimensions defining some of the discipline's key parameters. These dimensions and behavior principles (e.g., stimulus control, matching law, behavior momentum, and reinforcement) clarify how behaviors are shaped, exhibited, and adjusted across different environments. This insight is critical in educational settings. This paper moves beyond the clinical and classroom settings to explore these dimensions in the day-to-day life of a fictional character named Theo.

Specifically, we will examine the dimensions of applied, behavioral, analytic, technological, conceptually systematic, effective, and generality. These form a comprehensive framework for understanding and implementing behavior change. For an easy mnemonic to remember these dimensions, consider "GETACAB." Throughout Theo's day, his actions demonstrate these dimensions, providing a clear, practical application of how they guide behavior management and development. Accompanying the narrative, Table 1 presents a concise summary and initial exploration, setting the stage for a deeper discussion on each dimension’s role in behavior change and learning.

Table 1.

Some Dimensions of Applied Behavior Analysis

Theo’s Day in ABA Dimensions

Theo lived in the vibrant town of Happening. An ordinary guy with an extraordinary knack for planning, Theo was equipped with expertise in applied behavior analysis (ABA)—a science that empowers one to observe, predict, and control their surroundings effortlessly, with social validity and ethics. He was all set to transform an ordinary Saturday into an extraordinary adventure, one cab ride at a time.

Theo's day began with a breakfast fit for a camping trip but made in the comfort of his own kitchen. He adeptly applied his outdoor cooking skills to his urban setting, a perfect example of the ABA principle of generality—using what you learn in one area of life in a completely different area. Energized by his hearty meal and the city view from his balcony, Theo hopped into his first cab, eager to start his day in the park.

Theo focused on maintaining peace of mind at the park with his morning mindfulness exercises. This practice of effective stress-reduction techniques allowed him to be fully present in the day ahead. Practicing strategies with a strong and theoretical evidence-based was reassuring, but more importantly, practicing in his community and outside was especially grounding and personally meaningful to him. Theo hopped into his second cab, eager to take some photos driving around Happening.

With his camera in tow, Theo didn’t just aim to take good photos during the ride—he planned to excel. A field notebook summarized his technological knowledge of photography and his camera settings as he was still a novice. This level of technical precision enhanced his skills and brought structured creativity to his hobby, making each snapshot a testament to the power of understanding his newfound craft. As Theo left the park, he felt good about his photo session. But it was time to switch gears. His next cab ride would take him to the gym.

Theo applied specific behavioral techniques at the gym to optimize his workout. He had set clear, achievable goals for his exercise routine, using modeling, shaping, and reinforcement with his workout, he was confident his routine was enhancing in both performance and safety. Refreshed and reenergized from his workout, he was thankful for how meaningful those strategies came to his workout (not to mention his work in schools).  Theo caught another cab, ready to head to the cafe. As he relaxed into the seat, he pondered how each part of his day was connected through the principles he applied.

At the cafe, Theo reviewed the principles behind his day's successes. From morning until now, each activity was a practical application of ABA if he could be conceptually systematic in his thinking. For example, recalling how having his workout clothes in his backpack and not having to go home was a major antecedent setting event that allowed him to work out longer and harder. He was also pleased to recall what he liked about his indoor-outdoor breakfast (reinforcing what he would do in the future). Theo jotted a few more notes to understand better how ABA could bring about effective and meaningful change before calling his final cab ride.

Theo’s thoughts during his final cab ride of the day were introspective. He considered the successes of the day. Theo turned to his camera, analyzing his photo outcomes against the objectives he had set earlier. His photos demonstrated his training and weekly photoshoots helped with his craft. He looked at his pictures before the photography class, during the photography class, and after he started practicing every weekend. He wished he had taken more formal data to determine if a functional relation was evident. He wondered what design he could try; multiple baselines across camera settings seemed like a novel study.

Theo prepared for his end-of-day chores and evening relaxation routine at home. Following a routine schedule of behaviors and monitoring the time spent on each task maximized his recreation and leisure time before hopping into bed. As Theo settled down for the night, he reflected on his journey through the day – thankful for all that got him through. Each cab ride had transported Theo geographically and mentally, from one well-planned activity to another, each underpinned by ABA principles.

Authors Bio

Eric Common is an associate professor at the University of Michigan-Flint in the Department of Education and is a board-certified behavior analyst at the doctoral level.

Authors Note.

Portions of this newsletter article were developed with the assistance of ChatGPT, an AI language model created by OpenAI.

References

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97. https://doi.org/10.1901/jaba.1968.1-91.

Miss Kitty Advice Column

Miss Kitty

I almost turned in my resignation today. I just can’t take the pressure anymore. I love my students, but there are some other teachers that I have tried to work with, and they are mean to me. Today we were in a faculty meeting, and one of the other teachers in my middle school building announced in front of everyone that my classroom was too noisy when they are in the hall, and it is disturbing her students. Another teacher who is a friend of hers chimed in and agreed and said, “Can’t you control your students any better than you do.”  They asked the principal why I needed to be in the hall with my students. My principal backed them and told me we would have to stop painting the mural.

I teach a self- contained classroom of students with varying disabilities, and we asked permission to paint a mural on the wall outside the classroom and he agreed. Now he turned around and said we can’t do it anymore.  My students are very excited and are doing a nice job, but they do get excited and talk. I had no idea the teachers were upset. They never came to me, or we would not have talked in the hall. After the meeting was over, one of the teachers came up to me and said, “Well, I guess you got told. It’s a stupid mural anyway.” I left the building in tears.  I don’t want to go back there.

Angry Annie

Dear Angry Annie:

I am so sorry to hear this has happened to you. It sounds like the mural idea is a great project for your students and they are getting a great deal of enjoyment from it. I understand that the behavior of the other two teachers is very upsetting. It is too bad they chose to embarrass you in front of all the other faculty at a teachers’ meeting. I think it would be advisable for you to sit down with your principal tomorrow morning. If that is not possible, make an appointment to meet with him.  Before that meeting come up with some options that might make all parties happy. Until you can meet with the principal, I would suggest you tell your students that there is going to be a break from painting the mural without giving them the reason. Here are some suggestions:

1. Is there a time in the day when those two other teachers are at lunch or out of their classrooms and your class could work on the mural? Granted it may be disruptive to their classes if your students are talking when other classes are trying to do quiet work. Can you find another time to paint the mural, and present that to your principal? I know there are probably bus issues, but could you arrange to have your students come early or stay late to paint the mural.

2. Be prepared to be as factual and calm as possible with the principal when you are discussing possible solutions. 

3. Ask the principal for possible options so the students can finish what they have started on the mural.

4. I would not show any anger toward the teachers when you talk to the principal. What they did was inappropriate but to resolve this issue you need to talk to them directly. Otherwise, the principal may tell them you said something about them and that will build more resentment on their part.

5. I would then approach the teachers and talk with each of them separately and stay calm and ask them in the future if they could come to you directly when they have a concern. Let them know you want to work together with them and don’t want to disturb their classes and apologize that your class was disruptive to their classes.

I know it is very tough but try not to let the actions of these people destroy your love of teaching. Set a goal to try to resolve your differences with them for the benefit of your students.