Autism assessment in adult women: challenges and clinical considerations

Autism in adult women is still frequently under-recognised in clinical practice, often because the traits present differently from the patterns most diagnostic frameworks were built around.

Diagnostic tools and female presentations

In adult autism assessment, widely used instruments such as the ADOS-2 and ADI-R remain central to clinical evaluation. However, these tools were originally developed and standardised primarily on male samples. This has led to increasing discussion around whether current assessment tools are sufficiently sensitive to female autism presentations, particularly in adults.

How autism can present differently in adult women

Research, including a review by Hull, Petrides and Mandy (2020), and clinical experience suggest that autistic women are more likely to present with:

• More internalised repetitive behaviours
• Subtler differences in social communication
• Higher levels of masking or camouflaging
• Greater adaptation to social expectations over time

As a result, their presentation may not align as clearly with prototypical diagnostic examples.

This can make standardised assessment more complex, particularly when it relies heavily on observable behaviours within structured settings.

The role of masking in adult assessment

Masking (or camouflaging) is increasingly recognised as a key factor in adult autism assessment, especially in women.

Many individuals develop compensatory strategies that:

• Reduce the visibility of social differences
• Increase apparent social reciprocity
• Mask underlying cognitive or sensory effort

During assessment, this can lead to:

• Lower scores on observational tools
• Less obvious behavioural indicators
• Greater reliance on developmental history and clinical formulation

Common clinical presentations

In practice, many adult women referred for autism assessment initially present with:

• Anxiety disorders
• Depression
• Chronic burnout
• Eating disorders
• Emotional regulation difficulties

While these presentations are valid and require support, they may also reflect an underlying neurodevelopmental profile that has not yet been identified.

Challenges in adult autism assessment

For psychologists and clinicians, assessing autism in adult women often involves several challenges:

• Integrating multiple sources of information
• Identifying masking and compensatory strategies
• Interpreting subthreshold or atypical presentations
• Differentiating between overlapping conditions

This makes the assessment process more reliant on clinical judgement and structured integration, rather than any single instrument.

Towards more sensitive assessment approaches

Improving autism recognition in adult women does not necessarily require replacing existing tools.

However, it highlights the importance of:

• Structured anamnesis and developmental history
• Dimensional understanding of traits (rather than binary thresholds)
• Consistent mapping to DSM-5 criteria
• Attention to functional impact across contexts

A more integrated approach can help presentations be understood more fully, even when they do not fit traditional profiles.

Supporting clinicians in practice

At Lira, we are building tools to support clinicians working with adult women in ADHD and autism assessment.

Lira for Professionals provides a structured protocol that combines:

• Guided clinical anamnesis
• Structured questionnaires
• Dimensional profiles aligned with DSM-5 criteria
• Support for integrating findings into clinical reports

The aim is more consistent, gender-sensitive assessment, with clinical expertise staying with the clinician.

Explore the approach

If you are working with adult women and would like to explore a more structured approach to assessment:

See how Lira for Professionals structures the assessment →

References

• Hull, L., Petrides, K. V., & Mandy, W. (2020). The female autism phenotype and camouflaging: A narrative review. Review Journal of Autism and Developmental Disorders, 7, 306-317. doi:10.1007/s40489-020-00197-9