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Gender Bias in Autism Assessment: A Content Analysis of Gender-Linked Behaviors in Items of ADOS-2, GARS-3, and CARS2-ST
Saeed Hassan Zade , Sahar Zeynali *
Department of Psychology, Faculty of Psychology and Educational Sciences, University of Tehran, Tehran, Iran , saharzeynali@ut.ac.ir
Abstract:   (5 Views)
Introduction: Autism spectrum disorder (ASD) is one of the most common neurodevelopmental pathological conditions, with epidemiological data consistently indicating higher prevalence rates in boys than in girls. It remains unclear whether this sex difference reflects a genuine biologically based disparity or whether commonly used diagnostic instruments have been developed primarily around more overt and stereotypically male behavioral profiles. Existing evidence in this area remains limited and heterogeneous. The present study aimed to examine gender-related imbalance in the items of widely used ASD screening and diagnostic scales. Materials and Methods: Items from the Autism Diagnostic Observation Schedule–Second Edition (ADOS-2), the Gilliam Autism Rating Scale–Third Edition (GARS-3), and the Childhood Autism Rating Scale, Second Edition–Standard Version (CARS2-ST) were analyzed using a directed qualitative content analysis approach. In total, 91 items were examined through three cycles of open, axial, and selective coding to identify how social, emotional, and communicative behaviors are represented in each scale with respect to gender-related differences. Results: The findings indicated that, despite structural differences, all three instruments contained identifiable patterns of gender-related imbalance at the item-content level. This imbalance was primarily reflected in an emphasis on overt behaviors and patterns more frequently reported in boys in the research literature. Limited attention to social camouflaging, imitative coping strategies, and the presence of subtle or controlled behaviors observed in some autistic girls also emerged as an important theme. Cross-scale comparisons showed that the ADOS-2 appears more vulnerable to the masking of symptoms behind apparently typical behaviors, the CARS2-ST is more influenced by clinical judgments shaped by gendered social norms, and the GARS-3 places greater emphasis on more overt and male-typical presentations of restricted and repetitive behaviors. Examination of the gender composition of the norming samples further revealed that boys outnumbered girls by approximately 3:1 to 4:1 across all three instruments. Conclusion: Taken together, these findings, without rejecting biological or neuropsychological explanations for sex differences in autism prevalence, suggest that the content and norming characteristics of assessment instruments may contribute to the lower identification of girls, particularly those who use camouflaging and adaptive social strategies. Revising item content, attending to different presentations of autism in girls and boys, and developing gender-informed norms for future diagnostic instruments may warrant further consideration.
 
Keywords: Autism Spectrum Disorder, Sex Differences, Psychometrics, Diagnosis, Social Interaction
Full-Text [PDF 1623 kb]   (3 Downloads)    
Type of Study: Research --- Open Access, CC-BY-NC | Subject: Psycology
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