Why Is My Daughter Still Struggling? Autism in Girls and the Search for Answers
Feeling like you've tried everything, yet your daughter continues to struggle? If you've questioned if there's something more beneath the surface of anxiety, depression, or other diagnoses, you're not alone. Discover how autism uniquely presents in teen girls, often masked by social camouflage and leading to years of misdiagnosis. This eye-opening episode delves into the subtle signs, the crucial differences between autism and conditions like borderline personality, and offers a path toward understanding and effective support. If you're searching for answers and a deeper connection with your daughter, this conversation offers hope and practical steps.
If you're a parent who feels like something just isn't adding up with your daughter’s struggles, despite therapy, school support, or even multiple diagnoses, this episode is for you. Host Tiffany Herlin, LCSW, is joined by Allison Jenkins, LCSW, to explore how autism often shows up differently in girls, leading many to be misdiagnosed or misunderstood for years.
What You’ll Learn:
- Masking & Misdiagnosis: Why girls on the spectrum are often misdiagnosed with depression, anxiety, or borderline traits.
- The Hidden Spectrum: How social camouflage and high intelligence can mask the signs of autism in girls.
- Behavior vs. Connection: Understanding the deeper “why” behind behaviors like self-harm, social withdrawal, or risky choices.
- BPD or ASD?: How parents can distinguish between autism and borderline personality traits—two diagnoses that can look surprisingly similar.
- What to Watch For: Practical signs that your daughter might be on the spectrum, even if no one’s ever mentioned autism before.
If your daughter is struggling—and especially if treatment hasn’t been working—there might be more going on beneath the surface. This conversation offers hope, validation, and direction for families who feel like they've been missing a crucial piece of the puzzle. You’re not alone, and there are steps you can take to get the answers your family needs. Take the first step towards healing. To learn more about how you can help your child, call us at 855-701-2721.
Introduction to Autism in Females
Tiffany: Welcome to our podcast. I'm your host, Tiffany Silva Herlin, a licensed clinical social worker, and I’m so glad you’re here for this important conversation about autism, especially how it shows up in females and why it’s often overlooked.
Just a quick reminder: this podcast isn’t a replacement for therapy. Please seek help from a mental health professional for your specific situation.
In this mini-series, we’re diving into the complexities of autism diagnosis. We’ll explore topics like masking, the challenges many autistic females face in being properly identified, and the consequences of misdiagnosis. We’ll also talk about the importance of early and accurate assessment, and how residential programs like OASIS can provide comprehensive support.
Joining me today is Allison Jenkins, a licensed clinical social worker and the clinical director at OASIS, a residential treatment center. Together, we’ll explore research, share real-world insights, and offer guidance for parents, professionals, and individuals navigating this journey.
Let’s get started—because the more we understand, the better we can support and empower autistic individuals and their families to be seen for who they truly are. Thanks for joining us.
Allison: Thanks for having me—I’m excited!
Tiffany: You were part of our last series on suicide ideation, and at the end, you mentioned you had a topic you were passionate about and wanted to share.
Allison: Yep! Here we are.
Tiffany: So why do so many autistic girls go undiagnosed? In this first episode, we’re going to talk about masking, common misdiagnoses, and the more subtle signs of autism in females.
But first, tell us a little about yourself and how you became interested in this topic.
Allison: That’s a great question. I’ve been a clinician for 16 years, working in various treatment centers. When I came to OASIS, which focuses on assessment, stabilization, and treatment, I started noticing a pattern.
We had girls coming in who had been asked to leave other programs or who were struggling at home. They’d been misdiagnosed. They’d come in with one diagnosis, but after a thorough psychological evaluation, we’d realize they had Level 1 autism.
I didn’t set out looking for this—I just started noticing the trend. Something felt off in how these girls were being treated and diagnosed.
Tiffany: Like a missing piece.
Allison: Exactly. So I leaned into it. I started collaborating closely with our psychologist. Now, I want to clarify: as a licensed clinical social worker, I can’t diagnose autism—that has to come from a psychologist. But I look for the clues. I pick up on the nuances, talk with the parents, and work side by side with our psychologist to make sure we’re seeing the full picture.
Tiffany: That’s exactly what a skilled and experienced clinician does. While therapists like us can’t officially diagnose autism, it does take a team, especially in a place like OASIS. It’s about asking, “What are we missing?” and pulling together all the pieces that might have been overlooked by another provider. Then we bring that to the psychologist to help them put the full picture together.
Allison: Exactly.
Research Gaps in Autism Studies
Tiffany: And then let the psychologist do what they do best, right?
Allison: Yep.
Tiffany: Okay, Allison—so what makes autism in females different from what we traditionally think of as autism?
Allison: That’s such a great question. First, let’s talk about the research, because it’s pretty surprising.
Tiffany: Okay.
Allison: So when researchers conduct autism studies, there’s a requirement for a specific ratio in their samples: four males to every one female.
Tiffany: Really?
Allison: I’m completely serious.
Tiffany: Wow.
Allison: And that’s still happening today.
Tiffany: Why is that?
Allison: I think it’s because girls are often better at masking. They can hide their symptoms more effectively. And because of that, they’re underrepresented in the research. The data just doesn’t reflect the full picture.
Also, when girls are included in these studies, they’re usually the ones who show very clear, obvious traits of autism. But there’s this whole group of girls I call “the hidden spectrum.” They don’t present in the typical ways, and because of that, they’re often misdiagnosed or completely overlooked. The research just isn’t built to support or identify those girls.
Tiffany: Yeah.
Allison: So, from the start, females have been underrepresented in both research and diagnosis. The studies focus on girls who are more visibly autistic, while the ones who are masking—who are struggling quietly—don’t get the attention or support they need. But now, we’re finally starting to see more of those girls being identified. It’s eye-opening.
Tiffany: That reminds me of what we’re seeing with ADH, D too—so many women in their 30s are just now getting diagnosed. Same thing: they’re good at masking, and we’re just not catching it early enough.
Allison: Exactly.
The Role of Social Skills in Diagnosis
Tiffany: Is the masking we see in autistic girls connected to that social instinct many women have? I’m not saying men or boys aren’t social, but women often seem to have a deeper, more intuitive need for connection. Is that where masking starts? Can you help me understand?
Allison: Yeah, and it starts young.
Tiffany: Yeah?
Allison: When they’re little, they’re constantly trying to figure out how to fit into the world. If they do something funny and someone laughs, they learn from that. They’re reading faces, taking mental notes—like, “Okay, that was a positive interaction.” Over time, they’re building this mental Rolodex of situations where things went well.
Then they start developing these “masks”—different versions of themselves for different situations. “When I’m with my teacher, I act this way. With my therapist, I do this. With my parents, I wear this mask, and with my friends, I wear another.”
Tiffany: That’s so interesting.
Allison: And these girls are really smart, often with average to high IQs. They’re great at noticing what they need to do to fit in. They learn how to read social cues and show the right mask to get the reaction they want. That makes them feel good, and they get good at it.
Tiffany: Yeah, that makes sense. I used to work at a residential program for both boys and girls, and one of the biggest differences I noticed was that social element.
When boys had issues with each other, they’d usually hash it out—maybe not physically, but directly. Then it was done. But with girls, the social dynamics were so much more layered and complicated. As a therapist, navigating that social complexity was a whole different challenge. It was fascinating to watch the difference.
Let’s dive into some of the research you’ve been sharing.
Allison: Okay!
Tiffany: I remember some of the points from your presentation—you’ve shared this at conferences, right?
Allison: Yes, I’ve been trying to get the word out because I think this is such an important message.
Tiffany: I agree.
Allison: Especially for outpatient providers. These girls can walk into a session and smile, nod, and say everything is fine. They can hold the mask for an hour and appear completely neurotypical because they’ve learned how to mimic social behavior from their peers.
That’s why it’s so important for therapists and psychiatrists to understand this. In a residential or 24/7 treatment setting, where these girls are observed in different environments—school, therapy, peer groups, even community settings—they can’t keep the mask on all the time. Eventually, they let it down.
Tiffany: Yeah. It’s just harder to keep up the mask when someone is observing you that frequently.
Allison: Exactly.
Tiffany: Whereas in outpatient therapy, a clinician might only get a small glimpse into what’s going on.
Allison: Right.
Tiffany: They only see what the client tells them, and sometimes, the therapist might not even loop the parents in.
Allison: Yep. And that’s where things can easily be missed. Now, I’m not saying you can’t suspect autism spectrum disorder in an outpatient setting.
Tiffany: Of course.
Allison: And I’m not saying that everyone needs to go to residential treatment to get an accurate diagnosis. But I do want outpatient therapists, psychiatrists, and especially parents to start noticing the signs—and keep autism on their radar.
Tiffany: Yes. Whenn kids come into treatment with the wrong diagnosis, it can be harmful.
You miss the bigger picture. They might stall out in their progress—or even start to regress.
Allison: Yes. They can even be asked to leave the program.
Tiffany: Right.
Allison: And I want to talk more about that. When you place a neurodivergent girl into a program designed for neurotypical girls, especially if it’s a big group, like 65 girls, it can be overwhelming.
Socially, it’s just too much for them to manage. They can’t keep up. And what we often see is that these girls have been in programs for years... and eventually, they’re asked to leave.
Tiffany: Yeah, and that’s not how it should be. We don’t want kids stuck in treatment programs for years.
Allison: No. But then they come to us, and we realize, “Wait—this girl is on the spectrum.”
Tiffany: Yeah.
Allison: And with our trained eyes, we’ve gotten used to picking up on it. Once they have the correct diagnosis, parents and providers can finally give them the right kind of support and treatment.
Tiffany: This shortens the time they need treatment.
Allison: Exactly.
Tiffany: And it helps them get back on the right developmental path so they can keep progressing and eventually become a fully functioning adult, right?
Allison: Yes. Exactly.
Tiffany: So, what other research or data are we finding about all this?
Allison: The research we did at OASIS started when I began noticing this common pattern—girls coming in misdiagnosed. I call them the “question mark kids,” right? I’ll get a call from an educational consultant or a parent, and they’ll say, “Oh my goodness, I have no idea what’s going on with this girl.”
That’s the first red flag.
“She’s been in multiple treatment centers.” That’s another red flag.
“She’s been on multiple medication trials.” That’s the third. Because what’s happening is, providers are trying to medicate something they don’t understand. So they’re throwing meds at these girls like, “Maybe this will help? Maybe this?”
And I want people to know—it’s not because these girls don’t have depression or anxiety, but they're being treated for the wrong thing.
I’ve seen girls come in diagnosed with bipolar, and I’m like, “Wait, what?” And the most common misdiagnosis I see? Suspected borderline personality disorder.
Tiffany: Which we’re going to talk more about.
Allison: Absolutely. But the number one diagnosis I see on their charts when they come in? Major depression. That’s the big one.
So when I get these calls from parents or consultants and I start reviewing their clinical history, I see it over and over again—years of outpatient treatment, multiple diagnoses, lots of medication changes.
And I start thinking, “Okay… this could be suspected ASD.”
Tiffany: Yeah. And we’ve seen that around 30% of females with autism are misdiagnosed when they first come in. That’s a huge number.
Allison: Yeah. When we were collecting that data last year, I was honestly shocked. And if we collected that same data this year, I think the percentage would be even higher.
But what we found is that 33% of girls coming in are either misdiagnosed or treated with a Level 1 ASD diagnosis.
Tiffany: Wow.
Allison: Yeah.
Tiffany: Okay, so let’s talk about females versus males with autism. What are the differences there?
Differences Between Male and Female Autism
The Impact of Social Dynamics on Daily Activities
Tiffany: Interesting.
Allison: Another thing to look for is FOMO—fear of missing out. That shows up a lot. It can even interfere with hygiene or using the restroom. If they’re doing something social and enjoying it, they don’t want to leave to take a shower.
Tiffany: Right.
Allison: It just doesn’t make sense to them. Even leaving to use the bathroom, they’ll avoid it because they’re afraid they’ll miss something. So that’s another clue to look for.
Oh, and school refusal—that’s a big one too. A lot of these kids struggle with school. They don’t get the social cues, they fall behind academically, and sometimes they’re just overlooked. S,o school refusal is super common.
Tiffany: Which probably feeds into the anxiety they already have.
Allison: Yep. Or if they said something the day before and then processed it overnight—like, *“Oh no, I shouldn’t have said that”—*they might skip school the next day.
Tiffany: Yeah, that makes perfect sense.
Allison: Yeah.
Tiffany: So the bottom line is—they’re often viewed as attention-seeking when they’re connection-seeking.
Allison: Correct.
Tiffany: Which you’ve talked about—how we need to stop focusing so much on the behavior and start looking at the why behind it.
Allison: Yep.
Tiffany: Because they feel disconnected. That makes total sense.
Allison: Yeah. And I hate to say it, but social media plays a role too. There are self-harm groups out there, and girls can feel like they’re connecting with others, but they still feel incredibly alone.
Tiffany: Right.
Allison: They want to be in with their peers, but they don’t know how to socially connect. So they’re at home, scrolling social media, and finding connection in maladaptive ways.
Tiffany: Yeah.
Allison: Some girls will take pictures of self-harm or send them to friends. And it can look like borderline traits, but it’s not.
Tiffany: Yeah.
Allison: It’s them wanting connection.
Tiffany: That makes sense.
So, can you explain what masking is and how it plays a role in this diagnosis?
Allison: Yeah. Like I mentioned earlier, these girls learn from a young age how to socially fit in—how to present a certain way.
They know what kind of response they want, and they figure out how to get it. So they know how to mask in front of their teacher: “Okay, I smile. I sit in my seat. I raise my hand.” Great—one hour of their day.
Then they go to their next class and mask with their friends. Just trying to get that social connection. Laughing at jokes they don’t understand. Following people around. Trying to fit in. Trying to figure it out.
And they do that all day. And by the end of the day, they’re just exhausted.
They’re so emotionally and mentally drained.
And then when they get home, the mask comes off.
Tiffany: And that’s when you get all the behavior.
Allison: Exactly. That’s when you get the shutdowns, the isolation, the big outbursts.
Sometimes rage. And that rage can be misread—it can look like borderline personality disorder.
Tiffany: Yeah—BPD.
Allison: Or even bipolar.
Tiffany: Okay.
Allison: Or depression.
Tiffany: Yeah.
Allison: Or anxiety.
Tiffany: So let’s talk about challenges in diagnosis.
Challenges in Diagnosing Autism vs. Borderline Personality Disorder
Tiffany: You talked about how they can often be misdiagnosed with things like borderline personality disorder.
Allison: Traits—the traits, right?
Tiffany: The traits.
Allison: Yep.
Tiffany: So let’s talk about what that looks like. What is the difference? And what are some similarities we might see?
Allison: Yeah—and I think that’s the fascinating thing I’ve found. A lot of these girls come in with people saying, “Oh, it’s just borderline.”
Parents and outpatient providers will say that because of the self-harm, the suicidal ideation, the hypersexuality, possibly the rages or tantrums.
And if you put the symptoms for BPD and the symptoms for autism side by side, they match.
It’s a very complex process to tease out which is which, because autism is a neurodevelopmental disorder—
Tiffany: Yeah.
Allison: —that they’re born with.
Borderline personality, on the other hand, can have a genetic predisposition, but it’s usually caused by trauma or an invalidating environment.
That’s why testing is so important. We need to figure out: is this a neurodevelopmental disorder, or are these behaviors the result of trauma? Were they predisposed to something like BPD? Did they have a parent with BPD? That could also explain why the behaviors are showing up.
So again, it comes back to function—what’s driving the behavior?
And just to be clear, I’m not saying kids on the spectrum can’t have trauma—many do—but trauma isn’t the function of the behaviors.
Tiffany: We can put up the slide you have that shows the two sets of traits side by side. I think it’ll be helpful for our viewers to see that comparison.
Allison: Yeah. I’d love that. Because if we just go down the borderline personality traits, let’s break them down.
Tiffany: Yeah.
Allison: Poor interpersonal relationships, for example—
Tiffany: You’ve got autistic characteristics that make it difficult to make and keep friends.
Allison: Right—exactly.
Tiffany: Those look very similar.
Allison: They’re very similar. Then there’s rage. In BPD, you hear about these “BPD rages”—
Tiffany: And with autism, they also have anger and outbursts.
Allison: Yep.
Tiffany: Then we’ve got black-and-white thinking with BPD—
Allison: A hundred percent the same for someone on the spectrum.
Tiffany: And parents will say things like, “She had this best friend, and then one day the friend did something—we don’t even know what—and my daughter just blocked her and never spoke to her again.”
Allison: Or, “We used to go into this music store every week. She got along with everyone there. But then one day, someone said something—and she’s never gone back.”
I hear things like that all the time. And I’m like, “Okay, ding ding ding.” Those kinds of behaviors can look like BPD, but they’re often autistic traits.
Tiffany: Yeah.
And then next, we talked about this—attention-seeking versus connection-seeking. Which, honestly, even with BPD, we could say it's also connection-seeking.
Allison: Oh yeah.
Tiffany: Right? Self-harm—
Self-harm shows up in both. What else?
Allison: Yeah, I talked about that.
It's very prevalent in girls on the spectrum. And like I said, the function of it becomes… it becomes like a special interest and a form of connection.
Tiffany: That makes sense.
Allison: There's something called parasuicidal thoughts.
Tiffany: Okay.
Allison: And parasuicidal thoughts are those thoughts people have where they say, “Life is so hard—I just don’t want to be here anymore.”
Not, “I want to kill myself,” but more like—
Tiffany: “I just don’t want to deal with this.”
Allison: Exactly.
And when I talk to a lot of girls on the spectrum, that’s what I’m finding out.
They don’t want to die. They don’t want to kill themselves. That sounds painful and horrible.
And in their very logical, spectrum-oriented mind, it just doesn’t make sense.
But at the same time, navigating social interactions is exhausting.
I’ve talked to a lot of parents who say, “My daughter did so well in elementary school. She had friends, she had playdates, she did well in school—and then junior high came, and everything changed. I don’t know what happened. There was no trauma. She just became emotionally dysregulated, couldn’t go to school, and shut down.”
And I’ve thought a lot about that. So I started asking the girls, “Why was elementary school easy for you, and why did everything fall apart in junior high?”
The answer?
It’s the social navigation. In elementary school, they have one teacher, a small classroom, consistent structure.
They don’t have to constantly interpret or respond to complex social dynamics.
But junior high? It’s all social. New teachers, new classes, new kids, lunchrooms, cliques—it’s too much.
And if there’s any underlying anxiety or depression, that just magnifies the disconnection.
They feel like they don’t belong, and they start to tank.
That’s a huge red flag.
And I think there’s a myth that kids on the spectrum always struggle socially from a young age. But what we’re seeing with our girls is—they are socially engaged when they’re younger.
They mask well.
And then at some point, they can’t mask anymore. It becomes too hard.
Tiffany: Yeah.
Allison: And that’s another clue.
You have these parents who are just devastated—they felt like they had a neurotypical, healthy daughter.
Then she hits middle school and suddenly… It’s game over.
Tiffany: And that leads right into something we see a lot with borderline personality disorder—fear of abandonment.
Allison: Yep.
Tiffany: And an unstable identity, right? Extreme mood swings, versus someone on the spectrum who may drop friends, experience rejection sensitivity—
Allison: Yep.
Tiffany: And struggle to fit in.
Allison: Yep.
Tiffany: Dysregulation across the board.
Again, the behaviors can look similar, like a chameleon.
Allison: Yes.
Tiffany: It’s so easy to misread or mislabel what's going on.
Allison: Yes. And I think that’s where a real injustice has happened.
Tiffany: Yeah.
Allison: I hear it all the time—“Oh, it’s just borderline.”
Tiffany: Right.
Allison: “She’s just borderline.”
Tiffany: And in our industry, when you hear that thrown around like that—with that tone—it often doesn’t carry a very positive…
Allison: It carries a negative connotation.
Tiffany: Yes! Thank you.
It’s like, “Oh, she’s just being borderline.”
Allison: Exactly.
Tiffany: But the truth is—there’s more going on here.
Allison: And imagine being a parent who’s been told, “Your daughter has borderline personality disorder.”
They’re thinking, “What am I going to do with that?”
And then they hear, “Actually, she’s on the spectrum.”
Tiffany: Oh my goodness.
Allison: Yeah. Think about what a huge mindset shift that is.
These girls have been mislabeled over and over—“It’s just borderline.”
Misdiagnosis and Its Consequences
Allison: The approach often becomes, "Let’s treat them with DBT—this is just how they’ll be for the rest of their lives."
Tiffany: Right. And it’s worth pointing out—neither borderline personality disorder nor autism is something you can easily fix with medication.
Allison: No, not at all.
Tiffany: So it’s not like you can just throw meds at the problem and expect it to go away.
Allison: Exactly. That’s where all those medication trials come in.
Tiffany: Yep.
Allison: And when a teen has been through multiple med trials without improvement, that can feel like another confirmation to parents and providers that it must be borderline.
But when you dig into the function of the behaviors, you start to see—this is autism.
Tiffany: And that makes a huge difference in how we treat it.
For clinicians—and parents listening—you’re going to approach those situations differently.
Sure, there may be some crossover in treatment, but the overall path will not be the same.
Allison: Yes, and especially in residential treatment settings.
Girls on the spectrum often struggle in programs designed for neurotypical teens—that’s why they keep failing there.
But once they receive an accurate diagnosis, the right kind of treatment becomes possible.
We’ve diagnosed girls at 17 who have been in and out of programs since they were 13.
Once they finally got that correct diagnosis, they were able to transition home with the support they needed—and they stayed home.
Tiffany: That cycle—girls being passed from one treatment center to another—it’s heartbreaking.
Allison: It is. Because we’re missing what’s going on.
Tiffany: And that’s an injustice.
Allison: Absolutely.
Tiffany: It’s a disservice to the girls and their families.
Which brings us back to why a thorough, proper, and comprehensive evaluation is so important.
That’s how we make sure we’re serving the best interest of the families we work with—and giving them the real help they need.
Allison: Exactly.
Tiffany: Because otherwise, we’re just missing the mark.
Allison: Yes.
Tiffany: So you mentioned earlier that some girls come in with other diagnoses—let’s talk about what some of those might look like. What about narcissistic traits?
Allison: Narcissistic traits are another common misdiagnosis. Sometimes, it can seem like girls on the spectrum lack empathy.
Tiffany: Oh, yeah.
Allison: But it’s really because of the spectrum itself. They struggle with emotional reciprocity—it’s just harder for them to understand. Let me share a story to explain this better. I had a girl who had been diagnosed on the spectrum, and we were talking about emotions. She said to me, "I feel bad because I’ll see a girl in the corner crying, and I don’t care. What’s wrong with me?"
Tiffany: Oh, wow.
Allison: And I told her, "There’s nothing wrong with you. That’s part of your autism. You’re having trouble with emotional reciprocity."
Tiffany: And it doesn’t mean there’s something wrong with you.
Allison: Exactly. She had always felt like, "Maybe I’m a sociopath. Maybe there’s something wrong with me." I reassured her that it’s just how her brain works—she struggles with emotional reciprocity.
Tiffany: And that can sometimes look like a lack of empathy or narcissism, right?
Allison: Yes.
Tiffany: But that doesn’t mean they can’t have empathy.
Allison: Correct. They can learn empathy—it just doesn’t come as naturally as it might for others.
Tiffany: It's not how they’re wired.
Allison: Exactly.
Tiffany: And that’s helpful for parents and individuals who are struggling with this to realize. It’s not about something being "wrong" with them—it’s about understanding how they work and finding ways to help them grow.
Allison: Sometimes parents will say, "I think my child is antisocial."
Tiffany: I’ve heard that, too. It’s common when they struggle to make friends.
Allison: But just because they have difficulty in social settings doesn’t mean they’re a sociopath.
Tiffany: Right.
Allison: I want everyone to know, through the research we’re doing at OASIS, we’re finding that autism and anxiety often go hand in hand.
The Intersection of Autism and Anxiety
Allison: Autism and anxiety—imagine already having a brain that tends to perseverate on things, and then adding anxiety on top of that. It makes everything more intense. So, you end up perseverating about things and feeling nervous about things at the same time. What psychologists often do is tease apart what’s caused by perseveration and what’s driven by anxiety. Most of the time, they have both, but sometimes not. That’s the key difference.
Tiffany: That makes sense. If you're a female who's already more socially aware and you're on the spectrum, you know you don't always fit in. You know that sometimes you say odd things or do strange behaviors.
Allison: And you're trying to mask all day long.
Tiffany: Exactly. So, you’re holding it in, and that builds up to major anxiety, especially social anxiety.
Allison: Exactly. A lot of these girls will go home and think, “Did I say that right?”
Tiffany: They evaluate their conversations.
Allison: They review the whole day, thinking, “Oh, I should have said this. Was that okay?” That level of stress and anxiety, combined with their tendency to perseverate, can be overwhelming. They might get stuck on those thoughts, thinking, “I could’ve said this better,” or “Why didn’t I say that?” All of that builds up, and it’s no surprise they experience such high levels of anxiety.
Tiffany: It adds another layer to their struggles.
Allison: Absolutely. And it’s completely valid why so many of these girls need treatment.
Tiffany: Yep.
Allison: A lot of girls come in with symptoms that look like OCD, right? Parents will say things like, "She always needs to know what’s coming next, orShe’ss hyper-focused on the way she looks, or She’s fixated on something." But it’s not OCD—it’s more about how autistic brains thrive in structure and routine. They can get stuck on these things because they feel a sense of security in the predictability.
Tiffany: And for our listeners, can you define "perseverate"?
Allison: Perseverate—how do I explain it? It’s like a fixation. It’s their special interest, something that goes in a loop in a spectrum brain that’s hard to break out of.
Tiffany: Would it be accurate to say it's like tunnel vision?
Allison: Yes.
Tiffany: They focus on one thing and can’t get off of it.
Allison: Exactly. And sometimes, it can be healthy. We had a girl who was a track star, and she would perseverate on running. That’s a healthy example. But it can also be maladaptive. We had a girl who was perseverating on marijuana. It wasn’t about the marijuana itself, but sometimes it can be used to decrease social anxiety, which makes it maladaptive.
Tiffany: Right.
Allison: So we see both sides.
Tiffany: And this is similar to what you see in obsessive-compulsive disorder as well.
Allison: Exactly. So the girl I mentioned was perseverating on running. Her parents were like, “She has to get up at 6:00 AM, eat this special breakfast that I have to prepare, then go to the same track every day. She has to run 30 laps or she can't function the rest of the day.” So, the question is, is that OCD, or is it part of the spectrum?
Tiffany: Yeah.
Tiffany: That makes total sense. What about bipolar disorder?
Allison: Oh, bipolar. When girls come in with bipolar, it’s often because of behaviors like hypersexuality. Parents get worried because they see their daughter sneaking out to meet boys, sending pictures to make connections—things that seem hypersexual. Sometimes substance use can be involved as well, especially if they’re escalating their behavior. Even though they’re on the spectrum, this can be mistaken for bipolar. Also, mood swings—doing great during the day, then coming home and completely blowing up, throwing things, punching walls—that can be perceived as bipolar. But when you look at true bipolar, none of these symptoms match.
Tiffany: Yeah, that makes sense.
Allison: I think with a lot of these "question mark" kids, they end up with all kinds of diagnoses because people are trying to make sense of what's happening.
Tiffany: Yeah, exactly. And that brings us to major depressive disorder, which I know you’ve talked about. And then oppositional defiant disorder.
Allison: Right, defiant. Major depressive disorder (MDD) is particularly interesting because I get a lot of kids who come in with that diagnosis, especially from hospitals. When providers aren’t sure what’s going on, they often end up labeling it as major depression.
Tiffany: And it's easier for insurance purposes, too.
Allison: Exactly. Because insurance doesn’t always cover autism.
Tiffany: Yeah, but they’ll cover depression.
Allison: Yep. So, if a lot of things are happening and insurance won’t cover autism, they slap the MDD label on to get it covered. I’m not saying insurance doesn’t pay for autism, but it’s not a diagnosis that’s commonly reimbursed in hospital settings. So, major depressive disorder often gets tacked on, and I think that’s a misunderstanding. In our research, we’ve found that MDD is the most commonly misdiagnosed condition. Girls come in diagnosed with depression, but they leave with a diagnosis of autism level one.
Tiffany: That’s fascinating.
Allison: Yep, it’s the most misdiagnosed condition.
Tiffany: Anything you want to add about oppositional defiant disorder? We touched on it briefly.
Allison: Yeah, ODD is often just a result of rigidity, especially in certain family dynamics. It's interesting—when I get a girl who has a parent on the spectrum, I always ask, "Who in the family is neurodivergent?"
Tiffany: Yeah.
Allison: Autism is highly genetically predisposed. So as soon as I ask that question, I often hear, "Oh, yeah, she has a brother on the spectrum too." And then I’m like, "Wait, what?" Then I find out that one of the parents is also on the spectrum. And suddenly it all clicks. If a parent has neurodivergence and a child does too, you’re going to see some clashing.
Tiffany: Oh yeah, you're gonna get an explosion.
Allison: Exactly. Both the parent and the child can be rigid, with each having their quirks. They see these similarities in each other that they don't like, which leads to conflict. So when a parent says, "I know I'm a lot like my kid, and I just can’t stand it," I often find that the parent is also on the spectrum, which makes sense. This rigidity can sometimes come off as oppositional behavior.
Tiffany: Yeah, that makes sense.
Allison: If both the parent and child have neurodivergence, the friction is inevitable. But it can easily be misinterpreted as oppositional defiant disorder.
Tiffany: Oh yeah.
Allison: So, it’s not oppositional—it’s just a clash of similar personalities.
Tiffany: I love that you're taking a broader view of the situation, trying to look at the bigger picture and put the pieces back together. It does take time, experience, and expertise to say, "We're missing something here."
Allison: Yep.
Tiffany: So, what are the key signs that practitioners and families should look for when suspecting a misdiagnosis?
Signs of Misdiagnosis in Autism
Allison: Okay, I love these are the kinds of clues I look for. So, one big thing is difficulty with stomach issues.
Tiffany: Interesting.
Allison: Yeah. A lot of kids on the spectrum struggle with bowel issues, like constipation. I’ll have a girl come in, and the parents will mention, "Oh, she’s sensitive to this, has stomach problems, needs more time in the bathroom." That’s a big clue. Another thing is candy cravings. I get girls who obsess over candy, and that’s often a form of self-soothing for the spectrum brain. If they’re perseverating on candy, it’s a sign.
Tiffany: That’s fascinating.
Allison: Also, parroting is a big one. I’ll see girls mimicking speech or behaviors from their peers. They might come home with a new term, and parents are like, "What does that mean?" The response is often, "I don’t know. I heard it at school." A lot of social mimicking happens, too.
Tiffany: That’s such an interesting sign.
Allison: Yes. And self-soothing behaviors are common. I’ve seen girls wear the same pants for a whole week because they find comfort in them. They might rub the fabric when they're distressed. That sensory piece is huge. They might also have to listen to music all the time. Everyone loves music, but for them, it's like a constant need to self-soothe, especially in environments like school.
Tiffany: That sensory need is huge.
Allison: Exactly. Then, there are hygiene struggles. It’s not the usual struggles you’d see with a teen, but sometimes they won’t want to shower due to sensory issues—it’s just the feeling that bothers them. So they might look neurotypical in other ways, but they’re still facing challenges in terms of hygiene.
Tiffany: That makes sense.
Allison: Social navigation is another clue. Teens on the spectrum often experiment with identities—trying to fit in, trying to connect with people, and figuring out who they are. While some of this is typical for teens, it can be more intense for them. I also see multiple medication trials, which is often a sign that they're not getting the right treatment.
Tiffany: Yeah, that social navigation is tricky.
Allison: It is. Another thing I notice is that they’ll have friends, then drop them suddenly, which can be seen as borderline personality traits. Sometimes they don’t know the right number of times to text someone, like texting too much, or they may find a friend and then want to spend every minute with them because that person becomes their special interest.
Tiffany: These are all really helpful signs that parents can dial into, things they might otherwise overlook.
Allison: Yes, they often assume their child is just neurotypical.
Tiffany: And we've covered so much today—things that might look like a certain diagnosis but could point to something else. Parents can take a step back and ask, "Is this truly what's going on, or is there something we're missing?"
Allison: Exactly. Especially if treatment isn't improving the situation. If they’re going to treatment and not seeing progress, that’s a red flag.
Tiffany: Yeah, that makes sense.
Allison: A lot of times, they’ll change therapists, try a Partial Hospitalization Program (PHP), and then they blow out of that, go back to outpatient, and nothing is improving. They’re not getting the right treatment, so it makes sense they’d have setbacks.
Tiffany: For our listeners who aren’t familiar with PHP, what does it stand for?
Allison: PHP is a Partial Hospitalization Program. It’s a more intensive day treatment program.
Tiffany: Got it. More intensive than outpatient, for sure.
Steps to Take for Autism Evaluation
Allison: So, it's a more intensive day treatment support program.
Tiffany: Before we wrap up this episode, I want to ask you one final question: What are the first steps someone should take if they suspect autism in themselves or a loved one, especially if it's a female?
Allison: That’s a great question. As I’ve mentioned before, I can’t diagnose autism myself, but here’s the tough part: the testing is very expensive, and many parents just can’t afford it. Insurance companies don’t always cover it.
Tiffany: Do they ever cover it?
Allison: Sometimes, if it can be proven as a medical necessity. But often, it’s just not widely available. I’ve worked with school districts where we’ve accurately diagnosed a child with ASD, and the school districts were like, "We’ve never seen that before," or even worse, "We don’t believe it." Autism diagnoses are still a newer field, and many people aren’t on board with it yet. They don't always see the signs.
Tiffany: Yeah.
Allison: Exactly. And then there's the cost barrier. If a parent goes to the school and says, "I think my daughter might be on the spectrum, can we get testing?" the school might push back. And psychologists or providers are often booked out for months. My advice would be to get a thorough evaluation.
Tiffany: It’s worth the investment of time and money.
Allison: Absolutely. It’s worth your time, and it’ll save you money in the long run. Call your insurance company to see what they cover, and find out which local providers are contracted to do autism testing. But sadly, even some local psychologists might disagree. They’ll say, "I don’t think she’s on the spectrum," or "I don’t think she needs an ADOS." And that’s incredibly frustrating.
Tiffany: Sorry, what is an ADOS?
Allison: The ADOS is the Autism Diagnostic Observation Schedule, a standardized assessment that helps diagnose autism. It’s not the only tool, but it’s an important one. That’s one of the barriers we face: How do we get these girls tested, and how can parents afford it? It’s a real struggle.
Tiffany: And I think you’ve touched on this already, but it’s so important to not just find the right tester, but to make sure they have the right information. The team involved—therapists, parents, school staff—should all be collecting data so the evaluation is thorough.
Allison: Absolutely.
Tiffany: We’ll dive more into that process in our next episode. We’ll discuss what the diagnostic process looks like and how we can help our listeners better understand it.
Conclusion and Key Takeaways
Tiffany: Allison, thank you so much for joining us today. I love how you've titled this presentation, "Seeing Through the Mask: The Hidden Spectrum." It’s so helpful for parents and listeners to understand that if their daughter is struggling, not quite having her needs met, and not making progress in therapy, they may be missing something. There could be more to this puzzle, and autism might be a part of it.
Allison: Yeah.
Tiffany: Thank you for sharing your wisdom.
Allison: You're welcome.
Tiffany: Thanks again.