VYU Autism Center for Excellence Webinar

VYU Autism Center for Excellence webinar.

>> LORI ERNSPERGER: Hello and welcome. My name is Dr.

Lori Ernsperger, and today we're going to be talking about girls and women on the Autism spectrum.

Just to give you a little bit of information, I've written a book with a co-author, a mom, Danielle Wendel, and I'm going to be talking about her later.

She has a young daughter on the Autism spectrum, and we were very fortunate to write a book on girls under the umbrella of ASD. We wanted to as a parent, and me as a professional, we really wanted to bring a level of awareness and education to this issue of the gender disparity between girls and boys on the spectrum.

Danielle and I were also able to create a book that empowers girls on the spectrum and, so, if you get a chance to look at the cover of the book, I want to start by saying that that was written by a really incredible young woman by the name of Amanda

Lamunyon. And Amanda is just an amazing artist. And when we wrote the book, Amanda's mother said to

Danielle and I that Amanda had taken the title of the book, Girls

Under the Umbrella of ASD and she painted a picture for us. And sure enough, we got an E-mail of Amanda and her portrait that you see here and, so, we determined at that time that this had to be the cover of the book so that we could utilize the strengths of girls on the spectrum. Amanda diagnosed with Autism Spectrum Disorders, or Asperger Syndrome. So, if you look at that cover, know that this is a book that from beginning to end celebrates the strengths of girls and women on the spectrum.

Before we begin, I would like to just share a little bit of information about myself. I have worked with individuals with disabilities now for 29 years beginning as a classroom teacher and now I'm an Autism consultant and, so, I have the privilege of traveling and speaking to parents and professionals all over the world on the topic of girls and women on the spectrum, as well as other areas of Autism Spectrum Disorder.

I want to share here my E-mail address, because we have a short time together for this webinar, and I want to make sure that if you have any follow-up questions, questions about some of the content or a question about, maybe, a child that you're working with, feel free to E-mail me at [email protected]. That is also my website that provides information about the professional development that I provide to schools.

So we're going to be covering a few topics here in this session, and I want to reintroduce, here is Danielle, my co-author, Danielle Wendel, and that is her brilliantly smart and beautiful daughter Mattison Wendel. And really the reason why we wrote the book was because of Mattison, and we wanted to provide Mattison with some information about her own disability.

And we'll talk about that self-determination, as well, in part II of this series on Girls and Women with ASD.

But for today, this initial part I section, we are going to be looking at the gender disparity between males and females on the spectrum. For example, if you have a group of individuals on the spectrum, you're going to see more males than females. And why is that gender ratio? And I really want to review some of the preliminary findings on the differences, what may be contributing to the difference between males and females, beginning with the diagnostic tools themselves, looking at how we socialize, males versus females, and also considering the genetic protection that females might have for ASD.

So when we look at girls under the umbrella of ASD we know that they are under-diagnosed. We know there is a disparity, a ratio disparity, and so our goal, Danielle and I, our goal has always been to support their uniqueness, but also not just to label. It's not about getting a diagnosis, by any means. The goal is the services. To access appropriate educational interventions, and maybe outside therapy, treatments that are effective for girls and women. And so that diagnosis is so critical at an early age so that we can focus on early intervention and educational services. And hopefully with the information that I'm going to share with you today we can do a better job of detecting and diagnosing and providing an educational plan that meets the uniqueness of girls and women on the spectrum.

We know that without a diagnosis we're going to have poor outcomes.

If we don't intervene early with effective interventions, we know that girls and women have -- their quality of life will be diminished in terms of employment, housing or independent living, as well as having meaningful social relationships. So hopefully with this information we can have an impact on some of those outcomes for girls and women.

Now, many of us are familiar with Hans Asperger, who you see here.

It's interesting, if you go back to his original research, go back to 1944 and read his case studies, and he says in that original research that autistic personality is of the extreme variant of the male intelligence.

He actually goes on to say that he feels like he's discovered this area that only occurs in males. It is not something that is found in females.

So we, from the beginning, in the medical field and educational field, have looked at the male patterns of ASD. So we are getting ratios 4:1, and when we look at that Asperger's or mild ASD up to 9-11:1.

So if we look on a spectrum here, let's take this a little bit further in terms of a visual. So if we look at our continuum of ASD, when we talk about children that are more severely impacted, we are talking about children who might have a cognitive impairment or an intellectual disability, severe communication delays, we might consider that ratio to be about 4:1. Sometimes referred to as classical Autism or kids that are more severely impacted with Autism.

As we move along that continuum, mild ASD or what was in the DSM-IV referred to as Asperger syndrome, that ratio becomes 10:1 or 11:1. So clearly we are missing out or underdiagnosing that population as we move to that mild end of the spectrum.

And here is that quote from Hans Asperger, that it may be that there are no girls with Autism. Well, we know that's not true, but unfortunately, beginning at that time, we have started to focus on what do the male characteristics of ASD look like. So there is a gender disparity.

So here what we see is a little bit of a historical perspective. I'm not going to go through the dates, and you don't have to memorize those, but I think it's important to remember that when Asperger syndrome was added to the DSM in 1994, it was very few women, very few characteristics that focused on girls and women. And I love a quote by Dr. Ami Klin. He was at Yale at the time. He is at Emory at this point. Emory University. But he called girls and women the spectrum research orphans. Because if you look at publications 2000 up to 2005, you're going to find very few researcher or scholarly articles that even include women. As a matter of fact, if you look at a sample of research-based journals or peer review journal, you'll find that most of the sample sizes were males. And, so, they were research orphans. And that quote is still true today, unfortunately.

Another publisher, a researcher in the field, Dr. Huerta, and I'll come back to her quote, talks about girls are the white elephant in the room. When it comes to researchers, if you go to some of the national meetings or conferences on Autism, you will see that girls are the white elephant. They are not discussed. And that historical perspective is important for us to remember.

Now, when I talk about the why, why might we have these gender disparities, why are girls research orphans or the white elephant in the room, we have three preliminary findings. And they are preliminary, because it's only been of recent that we've even had any peer reviewed research that had focused on girls and women on the spectrum in the gender disparities or the characteristics that are different. So these are preliminary. We may find in the next decade, hopefully genetics will come along. We might see more information in that area. Or we might see that diagnostic tools are changed so that we are more inclusive of female characteristics. But let's start with those diagnostic tools. Are they not just the cause, but is there a correlation between the diagnostic tools and the gender disparity between males and females? Well, many of the diagnostic tools, the signs are more male characteristics.

So if you look at a screening tool for Autism, and there are some online, like the M-CHAT, they're going to ask the parents maybe a set of 20 questions, maybe a set of 30 questions, and this is what happened with

Danielle, my co-author, and it still happens today. Here is Mattison, age five. And she goes to the pediatrician, and the pediatrician is going to ask a series of questions. And those questions are hopefully to screen for children that are high risk of ASD. But if the questions say something like: Does your child run around the house a lot? Are they very hyperactive? Well, Mattison was not, so the answer was no.

The next question may be: Do they climb? Does your child climb up on book shelves or furniture in the house? Again, the answer was no for

Mattison.

Another question may be: How do they play with their toys? Do they play with trucks? Do they lineup their cars? How are that kind of restricted behaviors? And many of these early screening tools are geared towards male characteristics and, so, when they score for the points yes, you get a point; no, you get no points. A girl on the spectrum, someone like Mattison, may only score a 9 out of 20. That puts her at mild risk, or even no risk at all. Within the normal range. And so, she is not moved on to further testing at that time. So we have to look at those screening tools.

I've got a quote here from Dr. Simon Baron-Cohen, who is a research from Cambridge University, and he says that first hour of diagnostic interview may go very well and so girls may present themselves in a manner that the pediatrician or psychologist may not see those first signs. And, so, for Mattison, she played. And that is a question that was asked. Does she play? Yes, she plays. Danielle talks about her playing with her dolls. She plaid with her dolls. You have to explore that a little bit more in detail. She lined up her dolls. And not only did she lineup her dolls, but she took the baby's blanket and she covered up their faces because she didn't like to look at their faces. Those questions were not asked. What was asked is: Does she play with dolls? Yes, she plays with dolls. Well, that is normal, typical girl behavior at six or seven. So we need to look at these screening tools. Are the questions gearing the pediatrician or the psychologist to look at just the male characteristics?

Now, I mentioned Simon Baron-Cohen, and he wrote a book in 2003 called

The Essential Difference. And I encourage you to look at that book. But it was the first book that I read in my writing of the book on Girls Under the Umbrella, because he talked about empathizers versus systemizers, or people who systemize. And he was making a conclusion that individuals on the Autism spectrum are systemizers. So if you would quickly just review those characteristics under systemizers. They're more technical. They want to understand a system. They're based on empirical evidence or numbers. They are interested in classifying, organizing or closed or finite systems. So if you think about individuals with ASD and you compare those two lists of characteristics, you might say, individuals on the spectrum would be systemizers. Okay. That made perfect sense to me when I was reading his book The Essential Difference. And then I went on to look at his -- he has a little questionnaire in his book, and I looked through the questionnaire and how would an individual score. Remember, you have to take a test or you're going to be observed by a psychologist in order to be diagnosed. And, so, if you look at the questions in his -- that he includes in his book, you see that the questions lend themselves to male characteristics or systemizers. So how would a female with ASD score on that exact questionnaire? And, so, I have given you how Simon Baron-Cohen has interpreted the test results. I want you to just look at this quickly.

If you take a look at the scale in the corner of your screen, you're going the see some blue shading, you're also going to see some pink shading, and some red shading. Unfortunately for most of us we think blue is boys and pink is girls. So I apologize. I did not create this screen and, so, we're going to have to go with the way he presents it in the text.

So don't think blue as boys. Think blue as girls.

But if you look at a typical -- any woman or girl who might take this questionnaire, most of us, for myself, for example, we're going to fall, typical developing females, that TDF, typical developing females, we're going to fall in that light blue area.

Girls that are more empathetic/empathizers are going to fall in the more darker blue area.

Where do males fall? Males are going to fall in that light pink. So they are typical developing males, or TDM is in that light pink area.

Now, if I was a person on the spectrum and I was taking this questionnaire, I was being tested to see am I at high risk for ASD, my score will have to be in that red quadrant. So you see the arrow that is pointing down to the lower quadrant? That is where you have to score in order to be included under the umbrella of ASD. Now, think about how difficult that has to be for a female. If I'm a female, I'm up in the blue quadrant. I have to score even more, a higher score, in order to move that dial over into that red quadrant or down to that lower right-hand corner.

When males are already -- typical developing males are already going to score in that quadrant.

I know it might take you a minute to review that, you can certainly pause and go back and hear what I'm saying. This just gives you a visual example of how it might be more challenging for a girl on the spectrum to actually meet the cutoff scores that we had set in order to be diagnosed with ASD. And you can review more work from Simon Baron-Cohen.

So we look at these diagnostic tools or screening tool and clearly we see that girls will not fit that prototype. Even in interviews, as I mentioned with the pediatrician and Mattison, questions might be asked, do they play, what kind of interests do they have? Girls may have interests that other girls have in horses or ballroom dancing, and they don't fit the fascination that boys may have with more mechanical objects, like vacuum cleaners or fans or plumbing or condensation. Things that are more categorized in finite systems.

And, so, this is a book that might be of interest to you. It's

Asperger's and Girls, and it is a series of short chapters from people like

Dr. Tony Atwood. You also see a chapter from Temple Grandin. And it really brings more information about girls and women on the spectrum. And, so, when we look at those gender differences, this is another quote from

Simon Baron-Cohen on the issue that males have that higher level of activity. So when the doctor asks: Do they run around the house? The males are automatically, due to testosterone, are going to fall into that yes category, versus females may not be having that same level of hyperactivity.

This next slide is an excellent article that was just published recently in 2014 called the gender differences in emotionality and sociability by Head, McGillivray and Stokes. I encourage you to look at it, because it also takes -- it's in the journal of Molecular Autism

Journal, but it talks about we need to be comparing girls on the spectrum, or potentially on the spectrum, to other females. And that females, typical developing females, we look at a friendship questionnaire and we see that girls on the spectrum are much more in align with their typical developing females than comparing them to boys. So a very interesting article by that group.

Another one that you may look up -- and, again, there is very few.

This is preliminary. But Dr. Judith Gould is with the autistic society in the UK, and she has a great publication on the gender disparity called

Missed Diagnosis or Misdiagnosis. And she is with the Lorna Wing Centere.

And what I appreciate about what she is saying is some girls we are diagnosing, but with the wrong diagnosis. We are misdiagnosing them with things like anxiety disorder, mood disorders, depression, other areas, even eating disorders or anorexia. And, so, we tend to look at girls through that screen of other more female oriented. And she is also suggesting that we're missing the diagnosing completely. You can look up Dr. Gould's work and you can find that online. She also mentions that girls have difficulty with what is called theory of mind. And this, many of us are familiar, if you work in the field of ASD. Theory of mind is our ability to understand that people have thoughts and emotions that are not our own.

Again, going back to Simon Baron-Cohen, Dr. Cohen has written a book called Mind Blindness, where he explains that individuals on the spectrum, this is not specific to girls, have more difficulty understanding that emotional reciprocity with others. So there is actually a test that you can take called the Sally-Anne test. I am giving you a copy of it. You can go through this yourself. I won't read it to you, but this is one of the psychological tests originally used by Uta Frith, you might be familiar with her work, on trying to look at how individuals on the spectrum see the other person's perspective or see emotions from somebody else. And, so, what we see from some, again, preliminary research, that girls actually failed the Sally-Anne Test more than boys. Girls had a greater impairment.

Now, this study that I'm quoting is the Nyden Gillberg one from 2000, so it's quite old. And I am cautious about sharing that study, because when you look at the IQs of the individuals who they gave this Sally-Anne

Test to, they had a lower IQ in terms of if they had an intellectual disability. Was it the intellectual disability that interfered with their ability to understand theory of mind or was it the ASD? But it was interesting to me that girls failed the Sally-Anne Test as we would think that girls would have more empathy and have more understanding of other people's thoughts and emotions and feelings. So that might be another area that we need further exploration and research. Another one that came out at the IMFAR conference in this last year from the Journal of American Academy of Child and Adolescent Psychiatry, in

June of 2013, that clinicians are missing girls, again, this goes back to

Dr. Gould saying that the clinician from the beginning is already overshadowed by thinking of -- as a female comes into their office of typical female conditions. And I'm quoting Dr. Happe here. Are they looking at anxiety? Are they looking at PTSD? Mood disorders? And, so, their conclusion was there may be this kind of pre-determining of a diagnosis when presented with a female. So the awareness campaign is so important that we all take this information back. If you're a pediatrician, if you're a psychologist, we need to share this with our colleagues that this may be why we're seeing the gender disparity.

This is another study in terms of the diagnostic tools by Kopp and

GillBerg, that diagnostic tools are looking at male prototypes and they miss the internalizing behaviors of girls on the spectrum.

So that is one preliminary finding. Is it the reason that we have 4:1 or 10:1? Is the reason due to our diagnostic assessment tools?

Let's move on to the second theory or preliminary finding. Is it because the way we socialize girls? You've probably heard the quote "Sugar and spice is everything nice." That's what girls are made of. And so girls are socialized to be nice. As a matter of fact, we reinforce girls that are nice. We like to see that in the classroom or in our preschool setting. So if a girl is nice, if a girl is passive, if a girl demonstrates sensitive behaviors towards others, we reinforce that behavior. Do I have any BCBAs out there like myself? We know that behaviors that are reinforced occur more in the future. Behaviors -- if we reinforce that behavior, are more likely to occur in the future.

So when we look at socialization, if girls exhibit kind behavior, sensitive behaviors -- we have a quote from Zosia Zaks. If they show kindness towards others, then we know that that behavior is going to be reinforced. And, so, from my board certified behavior analysts, we know that behaviors that are reinforced are more likely to occur in the future.

So girls are socialized to be quiet, to be more passive. We like to see that in classrooms and preschools. And, so, if we look at those principles of applied behavior analysis, what is contributing in terms of those girl behaviors versus those male behaviors.

So we have a quote from Jean Kearns Miller that, if girls are compliant, they are going to be reinforced and maybe underdiagnosed. So we're looking at that socialization.

Here is just our three-part contingency when we look at applied behavior analysis. The three-part contingency says that if a response is reinforced, it is more likely to occur. And we know that girls who exhibit co-social behaviors under our general guidelines of typical female behaviors are going to earn more reinforcement.

This is a great quote from a parent that was provided for the National

Autistic Society, again in the UK, that girls mask it better. Girls realize that if they are quiet, if they mask those behaviors of ASD, oftentimes until they get home, because what you'll hear is parents say, as soon as they walk in the door, there is a melt down. Or the evenings are really difficult because during the school day they were masking that behavior. This mom is saying girls are better to mimic, and she's right.

We hear from a lot of women on the spectrum that they mimic other behaviors much easier than maybe males on the spectrum. And, so, it is interesting to see it from a parent's perspective, as well, that parents are reinforcing girls for displaying kind behaviors, compliant behaviors, quiet behaviors, and those behaviors tend to be repeated then.

Just a little quote from an individual on the spectrum who is saying that her daughter was diagnosed with ASD and that was finally when she was -- had to look at her diagnosis of PTSD and say, wait a minute, maybe that is not what it is. So we're seeing moms on the spectrum who have been misdiagnosed. When they have a family member diagnosed with ASD they go back, maybe visit the doctor. I've heard this same story from many families as I've interviewed for our book on Girls Under the Umbrella.

I also want to point out, this was a great opportunity that I've had in the past year to speak in Australia on this topic of girls. You know, we tend to have, kind of, tunnel vision. If you live in Virginia, if you live -- I live in Las Vegas. You know, we kind of have tunnel vision of where we live and we think the issues are just in our area. Is girls falling through the crack? Is that an issue here in the U.S.? Is that in your state? Is that in your school district? No, this is an international issue.

And, so, as I spoke to parents and females on the spectrum in

Australia -- and you can look at this in-depth coverage on a news show from

Australia. I thought it might be helpful if you want to go to that website to learn more. And you're going to hear parents talk about their children on the spectrum. But I went to the Facebook page of the Amaze conference, this is in Melbourne. Great parent organization. But two of the parents posted, and I wanted to include their posts on Facebook. Include some social media. This is current from parents. And the parent was watching the Dateline -- I'm sorry, the Lateline show and said, This is so sad but true. So many girls go undiagnosed and their behavior often just gets put down to being naughty. It's sad because it often leads to depression and low self-esteem with girls on the spectrum. So this was a post by a mom on the spectrum who was -- I'm sorry, by a mom who had a daughter on the spectrum.

And the second one, much of this report rings true for my 10-year-old daughter with ASD, particularly masking her symptoms at school and when out socially, being polite and giving eye contact.

So these are right from the pages of parents. They know what they're saying. Parents are often the experts on their child, but when they take the child to the pediatrician or psychologist for that 20-minute diagnostic interview, the daughter shows, as this mom is saying, she's polite, she may give eye contact, and then the doctor says no, she doesn't appear to be high risk of ASD.

So our third preliminary finding. So we've reviewed diagnostic tools, we've reviewed the socialization of girls and how that might be impacting or missing the diagnosis, and the last piece is the genetic factor. And what a difference an X makes. Meaning, for our chromosome, sex chromosome, girls have two Xs. And there is some, again, preliminary research to suggest that having that X chromosome, extra X chromosome, might be providing a layer of protection for girls.

There is an organization, and I was not familiar with this organization, so I encourage you to check them out, Organization for The

Study of Sex Differences in Science. They don't just focus on women on the spectrum. They look at how is Science researching women from women with diabetes, women with heart disease, women with other, maybe a mental health disorder. And they're looking at what are some of the ways in which researchers are examining women in Science. And what we see over and over again is that women are often -- let me go back to Ami Klin. Women are often research orphans. Not just in ASD.

There was a recent sleep study that was done, and this is an important topic for sleep apnea. Again, it's out of my competency area, but I was interested to see that women were not included as part of that study as well.

So, they have been also looking, this organization, the OSSD, again I encourage you to go to their website and see that this is not only an international issue but also in the sciences, that we are missing girls and women. But when it comes to ASD, is there a protection with that extra X chromosome? And, so, we're just beginning to understand that genetics does play a role in ASD. There has been some saying that maybe this is occurring in the fetus, so it's got a fetal origin within the genetics.

Those are all preliminary findings. But we do see that if there is a genetic component, that maybe that extra X chromosome is providing some protection.

The study of epigenetics goes on to look at how does the environment impact our genes. So this is very interesting, because there's been a whole discussion about are there environmental influences in Autism? And there has been a range of a study on different environmental factors.

Could they be interacting with the genetics, the two Xs? Do they interact differently with males verses females, those environmental influences?

Again, that is the study of epigenetics. And I know if you are like myself, that is outside your -- probably your area of expertise, but it's something we need to keep up with in terms of our learning and, so, I encourage you to look more in depth in terms of what are the geneticists talking about in terms of women and girls on the spectrum and those X chromosomes.

There's been just a few studies. Here is one in 2013. They did a twin study, fraternal twins with girls. One girl, one boy fraternal study, and they saw that girls did have a protection.

Now, this is a quote I've heard many times "One study does not research make." So this is one study. It provides us with some future implications for future research, but it doesn't mean that it is conclusive. But it gives us a lead that why aren't geneticists looking specifically at girls instead of doing a study that includes both males and females in genetic testing and ASD, let's try to use a set of females.

I love the quote from Ronald here from the University of London talking about, in order for girls to be diagnosed they have to be loaded up to the gills with risk factors. And, so, therefore it is very hard to do genetic studies, because how do we get enough women on the spectrum to do the study? So it is a catch-22. We need to diagnose girls on the spectrum. We need to do genetic testing. How do we find enough girls to be samples or participants in these research studies? So very interesting quote and study here from Ronald and Robinson.

Additional study. I mentioned IMFAR earlier. In 2013, IMFR, which is the International Meeting for Autism Research, they actually had a session where they did a panel study, or panel discussion on females and ASD. That is a big step forward, that we're at least targeting this area.

We had -- they had some people from Yale University talk about some of the genetic differences. That may only explain 20 to 50% of that gender ratio. So maybe it starts with gender, and then another layer with our diagnostic tools, and another layer with that epigenetics, or the environment, socialization. So genetics is not going to be the whole entire answer in terms of that gender disparity.

I was interested also to see that at Yale they have just begun a woman's initiative. They received $15 million grant from the National

Institute of Health to target specific issues around girls and women under the Autism umbrella. So that is a great move. You can go to the Yale

University's website on women and girls and you can follow what kind of research they're doing. It's just begun, so it's -- all of that is preliminary.

And, also, Ami Klin. Again, he is at Emory University, and he has been studying and reporting the differences how girls engage differently.

And I don't think that is a surprise to any of us, that girls are going to behave differently than boys. How are we looking at those diagnostic tools to ensure that they encompass women and girls and those characteristics. Making a good point, they may have more eye contact. So we don't want that pediatrician or that psychologist to predetermine a diagnosis because the young girl, the six-, seven-, eight-year-old came into that setting and looked at the doctor and said hello. That does not mean you can't have

In addition, these are a few other studies that I wanted to include that you can continue to investigate and follow some of their preliminary findings, but there was a study on the head circumference of females in

ASD. If something is important, it is worth repeating. Remember, one study does not research make, so does this head circumference, can we use that as a way of differentiating between males and females? This was a study out of Israel in looking at the difference between females and males head circumference.

So, in conclusion, I know I've given you, hopefully, a brief overview of where you can continue your training. We are in the preliminary stages of understanding the gender disparity between males and females, but when

Danielle and I, my co-author on this Girls Under the Umbrella, starting in

2004 we went out to coffee. All things start over a cup of coffee.

And we sat there and we said, why aren't we doing more about girls? She has a daughter on the spectrum. She said, everything I'm reading is about boys. We need to do something about that.

And sure enough, we did. We created a campaign. We created awareness. It is so amazing that now her daughter, young at the time, is this amazing young woman who she now is presenting and talking about her own experiences. And we need to do that. We need to empower women and girls on the spectrum to share their stories. In part II I'm going to talk more about self-determination and advocacy among women and girls on the spectrum. But it does start -- you can start that conversation, if you're a parent watching or professional, start with your colleagues so that we can create more of an awareness campaign, more professional training so that those clinicians, your psychologists, neuropsychs, psychiatrists, medical doctors, are able to screen successfully for girls and women on the spectrum so that we can learn more about those differences.

Again, it's not about the label. It's not about just getting the diagnosis. It's about outcomes. And we know that without an appropriate diagnosis, and then an educational eligibility of ASD, we don't receive services. Children will miss out on those early intervention opportunities for related services, social skills training in schools and, so, it's not just about getting that diagnosis, but we want to make sure that we're recommending that we further create that educational plan that is going to be appropriate for girls on the spectrum.

A little quote from families. This was an important -- to remember our families, our parents out there. They have been a huge voice. Parents like Danielle that have said, we need to include family interviews more in that diagnostic procedures in terms of those -- it's not just a score on the ADOS. It's not just a score on the M-CHAT or whatever other screening tools you're using. But the family interviews, looking at that interview, what is the parent saying, going a step further, asking those more in-depth questions on girls and women.

And, so, here is a few outcomes in terms of where can we be going. Future findings. And, as I mentioned, we should be able to look at girls in research separate from boys in order to distinguish between the characteristics and looking at what would be better interventions, which

I'll get into more detail in part II. We want to be able to compare girls to typical developing girls and not to males or typical developing males.

And I'm going to end here. This was a book. It's been around for quite some time. I'm not familiar with all the women who contributed to this book, but yet I find their voices to be very compelling, and the reason why I do what I do in terms of my work, the book is called, you can still find it, Women From Another Planet. But I think here is the editor of that book talking about the underdiagnosing of women really marginalizes females. And they end up staying in the background. And if we don't create an awareness, and education campaigns, initiatives like what is happening at Yale University, they will continue to be marginalized and live in isolation. So I hope those words from this woman on the spectrum can help propel us further down the road to understanding girls and women under the umbrella of ASD.

I want to thank you. Again, my name is Dr. Lori Ernsperger and you can contact me for any questions or follow up at [email protected]. Thank you very - - - much.