title: An investigation of the 'female camouflage effect' in autism using a computerized ADOS-2 and a test of sex/gender differences.
abstract: BACKGROUND
  Autism spectrum conditions (autism) are diagnosed more frequently in boys than in girls. Females with autism may have been under-identified due to not only a male-biased understanding of autism but also females' camouflaging. The study describes a new technique that allows automated coding of non-verbal mode of communication (gestures) and offers the possibility of objective, evaluation of gestures, independent of human judgment. The EyesWeb software platform and the Kinect sensor during two demonstration activities of ADOS-2 (Autism Diagnostic Observation Schedule, Second Edition) were used.
  
  
  METHODS
  The study group consisted of 33 high-functioning Polish girls and boys with formal diagnosis of autism or Asperger syndrome aged 5-10, with fluent speech, IQ average and above and their parents (girls with autism, n = 16; boys with autism, n = 17). All children were assessed during two demonstration activities of Module 3 of ADOS-2, administered in Polish, and coded using Polish codes. Children were also assessed with Polish versions of the Eyes and Faces Tests. Parents provided information on the author-reviewed Polish research translation of SCQ (Social Communication Questionnaire, Current and Lifetime) and Polish version of AQ Child (Autism Spectrum Quotient, Child).
  
  
  RESULTS
  Girls with autism tended to use gestures more vividly as compared to boys with autism during two demonstration activities of ADOS-2. Girls with autism made significantly more mistakes than boys with autism on the Faces Test. All children with autism had high scores in AQ Child, which confirmed the presence of autistic traits in this group. The current communication skills of boys with autism reported by parents in SCQ were significantly better than those of girls with autism. However, both girls with autism and boys with autism improved in the social and communication abilities over the lifetime. The number of stereotypic behaviours in boys significantly decreased over life whereas it remained at a comparable level in girls with autism.
  
  
  CONCLUSIONS
  High-functioning females with autism might present better on non-verbal (gestures) mode of communication than boys with autism. It may camouflage other diagnostic features. It poses risk of under-diagnosis or not receiving the appropriate diagnosis for this population. Further research is required to examine this phenomenon so appropriate gender revisions to the diagnostic assessments might be implemented.
authors.affiliation: Department of Psychiatry, Medical University of Gdansk, Gdańsk, Poland ; Centrum Diagnozy, Terapii i Edukacji SPECTRUM ASC-MED, Gdańsk, Poland.
authors.forename: Agnieszka
authors.initials: A
authors.lastname: Rynkiewicz
authors.affiliation: Machine Intelligence and Signal Processing Group, Technische Universität München, Munich, Germany ; Department of Computing, Imperial College London, London, UK ; Chair of Complex and Intelligent Systems, University of Passau, Passau, Germany.
authors.forename: Björn
authors.initials: B
authors.lastname: Schuller
authors.affiliation: Machine Intelligence and Signal Processing Group, Technische Universität München, Munich, Germany.
authors.forename: Erik
authors.initials: E
authors.lastname: Marchi
authors.affiliation: Casa Paganini-InfoMus Research Centre DIBRIS, University of Genoa, Genoa, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Piana
authors.affiliation: Casa Paganini-InfoMus Research Centre DIBRIS, University of Genoa, Genoa, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Camurri
authors.affiliation: Department of Psychiatry, Autism Research Centre, Cambridge University, Cambridge, UK.
authors.forename: Amandine
authors.initials: A
authors.lastname: Lassalle
authors.affiliation: Department of Psychiatry, Autism Research Centre, Cambridge University, Cambridge, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Baron-Cohen
mesh_terms: D020817:Asperger Syndrome / Q000175:diagnosis* / Q000523:psychology; D001321:Autistic Disorder / Q000175:diagnosis* / Q000523:psychology; D002648:Child; D002675:Child, Preschool; D003147:Communication Disorders / Q000175:diagnosis* / Q000209:etiology; D003469:Culture; D003936:Diagnosis, Computer-Assisted / Q000379:methods*; D003951:Diagnostic Errors; D004644:Emotions; D005149:Facial Expression; D005260:Female; D005403:Fixation, Ocular; D005868:Gestures; D006801:Humans; D008297:Male; D010290:Parents; D011044:Poland; D011597:Psychomotor Performance; D012720:Severity of Illness Index; D012727:Sex Characteristics; D012737:Sex Factors; D012919:Social Behavior; D012984:Software; D013239:Stereotyped Behavior; D011795:Surveys and Questionnaires
keywords: ADOS-2; Computer application; Diagnosis; Females with autism