These coping and camouflaging mechanisms may mask the characteristics of AS for some time, such that the girl slips through the diagnostic net during the elementary school years. However, there is a psychological cost that may become apparent only in adolescence. It is emotionally exhausting to be constantly observing and analyzing social behavior, trying not to make a social error; adopting an alternative persona can lead to confusion with self-identity and low self-esteem. The stress, strain, and exhaustion of intellectually analyzing social situations and acting normal but being rejected, bullied, and teased can result in the development of depression, an anxiety disorder, eating disorder, or borderline personality disorder. The clinician diagnosing or treating these secondary mood or personality disorders can then identify the characteristics of AS when exploring the developmental history of the girl. Psychologists and psychiatrists therefore need a paradigm shift in their recognition of the female presentation of AS to ensure earlier diagnosis and access to effective understanding and support for girls with AS.
Signs of AS in Girls
In the preschool years the first signs of AS in girls can be intense emotions, especially distress, and an inability to be comforted by affection. Another sign is intense despair not alleviated by distraction or conversation. There can be aspects of sensory sensitivity, especially tactile and auditory sensitivity, resistance to change, and unusual characteristics in language development. While speech may not be delayed, the linguistic profile of a girl with AS can include problems with pragmatic aspects of language, the art of conversation, and being pedantic.
Parents notice that their daughter may not identify or want to play cooperatively with her female peers. She may consider that the play of other girls is beneath her—boring and inexplicable—and prefer to play alone so that she can do things her own way. Her interests can be different from those of other girls, not necessarily of focus but of intensity and quality. There may be a determination to organize toys rather than share them and not play with toys in conventional ways. For example, she may collect over 50 Barbie dolls yet choose not to enact with her neighborhood friends “Barbie getting married” but instead arrange the dolls in particular configurations. She may even use her dolls to re-enact scenes from school to try to decipher the codes of social conduct experienced during the day. She may prefer nongender specific toys such as Lego or playing with toys associated with boys, such as construction sets and vehicles.
The girl with AS may not be interested in the latest craze for girls her age to be cool and popular. She may also be averse to the concept of femininity, choosing not to wear the latest fashions, fancy or frilly clothing, or clothing with bright colors or complex patterns. Her preference may be for practical, comfortable clothes with many pockets.
While boys with AS may fixate on facts (and some girls with AS can also have an encyclopedic knowledge of specific topics), many girls have an intense interest in reading (and some are hyperlexic, exhibiting a precocious ability to read). They may develop an amazing vocabulary and escape into fiction, enjoy a fantasy world, talk to imaginary friends, and write fiction at an early age. Another escape for girls with AS is the exciting world of nature as many have an intuitive understanding of animals. Animals are safe: they are loyal, enthusiastic, and appreciative friends who never tease or reject.
Diagnostic Characteristics of AS in Girls
> not motivated to play with female peers
> imitate peers to camouflage social confusion
> escape into a world of fiction or nature
> not interested in the typical play activities of female peers
If a girl with AS does have a friendship, it is likely to be quite intense and with one other girl, who may provide guidance for her in social situations—an “unpaid paraprofessional” in the classroom. In return the girl with AS is a loyal, helpful friend rarely interested in the unfriendly behavior of her peers. Unfortunately the girl with AS can be vulnerable to friendship predators who take advantage of her naivety, social immaturity, and desperation for a friend.
Since it is inevitable that there will be times when she has to engage with other children, the girl with AS may well prefer to play with boys, whose play is more constructive and adventurous rather than emotional and conversational. Many girls who have AS have described to psychologists and in autobiographies how they sometimes think they have a male rather than a female brain, having a greater understanding and appreciation of the interests, thinking, and humor of boys. The girl may be described as a tomboy, eager to join in the activities and conversations of boys rather than that of girls, and they develop talents in school subjects that are predominantly male dominated, such as mathematics and science.
The adolescent girl with AS may not follow society’s expectations of femininity; for example, she may prefer to wear practical, comfortable, somewhat masculine clothing rather than dressing in a fashionable or feminine way. She may also have an aversion for the tactile and sensory aspects of makeup and perfume.
During their adolescence some girls with AS are known at school for their good behavior. A strategy often used is to be extremely well behaved and compliant in class so as not to be noticed or recognized as different by the teacher.
Adolescent girls with AS are often late to develop romantic relationships, having an almost puritanical attitude toward intimacy. Their first intimate experiences can be several years later than peers. There is an alternative trajectory: adolescent girls with AS can develop low self-esteem due to bullying and teasing by peers, and rather than follow social and moral conventions decide to actively contradict them, becoming vulnerable at a relatively early age to relationships and even to sexual predation. They may not have the intuitive ability to identify disreputable characters, tend to set their relationship expectations very low, and often experience multiple abusive relationships.
When a social mistake is recognized by boys with AS, they are likely to become agitated and disruptive; girls with AS, in contrast, are more likely to apologize and appease when making a social error. Peers and adults may then forgive and forget without realizing that a pattern of social errors is emerging. However, the girl with AS increasingly recognizes her own social confusion and frequent faux pas. She may react by trying to stay on the periphery of social situations (to not be noticed in a group) so that others remain unaware of her social confusion. She may develop a pathological fear of making a social mistake, and intense performance anxiety in social situations with peers can lead to selective mutism, an inability to speak when talking is expected.
A girl with AS may suffer her social confusion in silence and isolation on the playground yet be a very different person at home. The “mask” is removed, and she may use passive-aggressive behavior to control her family and social experiences—the opposite of the cooperative and compliant child at school. The confusion, tension, and suppressed emotions that occurred during the school day are released with some ferocity, such that she has almost two personalities: the meek school girl and the defiant, argumentative, and emotionally volatile daughter at home.
Coping Mechanisms for Girls with AS
Imitation. Some girls with AS adapt to being different by engaging in imitation. The girl may identify someone who is socially successful and popular, either a peer or a character in a soap opera, and adopt that person’s persona by mimicking speech patterns, phrases, body language, and even clothing and interests. She becomes someone else—someone who would be accepted and not classified as different. She learns how to act in specific situations, a strategy so successful that people may not be aware that the social abilities were a performance achieved by intellect and imitation rather than intuition and inspiration.
Girls who have AS can be like chameleons, changing personas according to the situation, with no one knowing the genuine person. Often the girl believes that the real person must remain secret because she fears that person is defective and must never be revealed. However, this coping strategy leaves her exhausted, and like Cinderella at the ball at midnight, she cannot keep up the social charade indefinitely. When she returns home from school, she cannot tolerate any more social experiences—even with family members.
Imagination. Some girls with AS may not seek integration but instead escape into imagination. The girl might feel that if she cannot be successful with her peers, she can try to find an alternative world where she is valued and appreciated. She may identify with a fictional character such as Hermione Granger of the Harry Potter series, who faces adversity but has special powers and friends. If she feels lonely, then talking to imaginary friends can provide companionship, support, and comfort. Alternatively she may develop an interest in ancient civilizations to find an old world where she can feel at home. Or she might acquire a fascination with another country, such as Japan, where she might be accepted and among people of like mind. She may develop an intense interest in science fiction or in the fantasy worlds of fairies or mythology. Many typical children occasionally enjoy escaping into imagination, but for the girl with AS, the reasons are qualitatively different. This is not evidence of the potential to develop a psychosis but rather the fantasy world becomes a constructive means of avoiding (not distorting) reality and experiencing a relatively safe, successful, and alternative social life.
We have only recently discovered that there are many more girls with AS than we first thought. We are gradually finding them earlier, but what we need to discover next is how to modify our existing programs for children and adolescents with AS to accommodate the adaptations used by girls and improve their social experiences and abilities with female peers. For example, we can use the constructive adaptation of imitation in drama classes with a curriculum specifically designed for girls with AS. At our Minds and Hearts Clinic (www.mindsandhearts.net) in Brisbane, Australia, we have friendship and emotion management groups exclusively for girls. I know of several colleagues who are specializing in the diagnosis and treatment of girls and women with AS in Australia and the US. We now have gender-specific resources on the profile and needs of girls and women with AS (see Resources below) and presentations by clinicians focusing on the abilities and needs of girls and women. While girls with AS may have different ways of coping particular to their gender, we are finding additional ways to diagnose them earlier and help them to cope so that they can develop their full potential.