Autism in girls — why we diagnose them later and what is already visible in preschool

TL;DR

Autism is not a “boys’ diagnosis.” Boys are diagnosed in greater numbers and earlier mainly because the diagnostic criteria, screening tools, and cultural images of autism were all built on male samples.
Girls on the spectrum mask more often — they copy peers, rehearse social scripts, suppress stimming, and compensate with perfectionism. Masking is socially effective and very costly on the inside.
The presentation of symptoms in girls tends to be “quieter”: ostensibly typical interests, one “best friend,” intense post-preschool withdrawal, eye contact “on command.”
“Polite, quiet, very mature for her age” is sometimes the full description of a child who is paying a high price for not making trouble. A mismatch with expectations switches on adult attention; a match with expectations puts that attention to sleep.
The spectrum can be recognised already in a two- or three-year-old. In practice, many girls receive their diagnosis much later — sometimes only in adolescence, often “on the way” through anxiety, depression, or autistic burnout.
An earlier diagnosis does not change the child. It changes only one thing, but a fundamental one: how long she has to pretend to be someone else in order to be accepted.

I have worked with children for over twenty-five years, and for most of that time we “saw” autism differently. In the textbooks, in trainings, and in our heads, the typical child on the spectrum had one face: a boy who did not make eye contact, lined up his toys in a row, and recited timetables.

That picture is not false — it describes a portion of autistic children. But it is incomplete. And it is precisely this incompleteness that meant a whole generation of girls passed through preschool, primary school, sometimes even high school, with no name for what they were going through. They received their diagnoses only when the external “costume” stopped holding — most often in adolescence, alongside anxiety, depression, or burnout.

This text is about what we, adults — parents, teachers, therapists — have a chance to see earlier. Not so that we can hand out diagnoses (that is what specialists are for), but so that we stop overlooking girls for whom things are simply hard.

Why we diagnose girls later

For years the epidemiological data spoke clearly: boys are diagnosed on the spectrum four to five times more often. That ratio made its way into textbooks, into the media, and into common awareness. Only in the last fifteen or so years did it turn out that this is not the whole truth — and that to a large extent it may be an artefact.

Three things combined to produce this belief:

The diagnostic criteria were written based on boys. The first descriptions of autism (Kanner, 1940s; Asperger, 1940s) were based almost exclusively on male cases. Subsequent classifications (DSM, ICD) inherited that assumption for a long time. The result: if a girl presented the spectrum “in her own way,” she did not match the criteria — and was not recognised.

Screening tools repeated the same mistake. Classic questionnaires asked about behaviours statistically more common in boys: technical interests, overt stereotypies, lack of eye contact. A girl who “is into horses” and makes eye contact “on command” passed through the sieve unnoticed.

Cultural expectations of girls reinforce masking. From early childhood, girls receive a strong message: “be nice, be quiet, be helpful, don’t be trouble.” A girl on the spectrum who hears this message has a real motive for training herself to be “within the norm” — even if it costs an enormous amount of energy.

The conclusion is modest and important: the real ratio of diagnoses is probably much closer than historical data suggest. A 2:1 ratio is increasingly quoted in the literature, and among adult diagnoses the proportions are even closer.

Masking — the most important concept of this conversation

Masking (sometimes also called camouflaging) is a set of strategies that allow a neurodivergent person to pass in their surroundings as “neurotypical.” It can be conscious (“now I’ll smile and say hi”) or unconscious, trained over years of trial and error.

Masking in a girl of preschool or early-school age tends to look something like this:

She watches her peers very closely — learning what is expected of her. She copies gestures, intonation, conversation topics, ways of laughing. Many girls later say: “I always had the feeling I was playing a role I didn’t quite understand.”
She rehearses social scripts. She runs the questions she expects from peers through her head and practises answers. She has “safe” topics she returns to in order to keep a conversation going.
She suppresses reactions she finds “strange.” Stims (spinning, hand flapping, repeating words) she does in private — or she swaps them for more acceptable ones: playing with her hair, biting her lip, fiddling with her sleeve.
She picks one closest friend instead of a group. One relationship is manageable; group dynamics is cognitively too expensive.
She compensates for deficits with perfectionism. She knows “something isn’t going right for her,” so she controls what she can: her appearance, the arrangement of her teddies, the precision of her drawing. Perfectionism here is not a character trait but a defensive strategy.

Masking is not manipulation or “pretending” in the everyday sense. It is a social survival strategy — and it often works remarkably well. From a teacher’s perspective, such a child can look downright exemplary: quiet, well-behaved, mature, “undemanding.” All the work behind that impression is happening below the surface — and is usually visible only at home, in the evening, when the mask comes off.

Symptoms of the spectrum in girls look different from those in boys

The autism spectrum has the same “cores” in every child: difficulties in social communication, rigid patterns of behaviour and interests, differences in sensory processing. But the surface on which it shows up in girls can be quite different from the classic descriptions.

Eye contact. Many girls on the spectrum have learned to look into other people’s eyes “on command” — because they know adults expect it. Yet often they look not at the pupil but at the space between the eyebrows, the mouth, or the nose. Briefly, with control. The classic “doesn’t make eye contact” test is of little use here — she does make it, but the looking is trained, not natural.

Interests. The passions of boys on the spectrum often “stand out” from the group: timetables, dinosaurs, the solar system, car brands, statistics. Girls more often pick culturally neutral or “girly” topics — horses, unicorns, books, characters from a favourite cartoon, painting, dance. It is not the topic that signals the spectrum, but the intensity, exclusivity, and depth: how many hours a day, whether the topic comes back in every conversation, whether the child reacts with strong discomfort when she has to leave it.

Communication. In preschool-age girls on the spectrum, speech is sometimes unexpectedly rich — they may speak “like an adult,” use bookish expressions, recite dialogue from cartoons. We often read this as a sign of above-average intelligence. It may well be — but it can also be functional echolalia, using memorised fragments as a way to communicate when spontaneous formulation is difficult.

Stims. Stereotypies in girls are usually subtler: playing with hair, biting lips, repetitive small finger movements, rocking a leg under the table, chewing pencil ends, putting sleeves in the mouth. It is easy to interpret these as “nervous habits” — which leads to trying to extinguish them rather than understanding that they serve regulation.

Outbursts. The classic image — an autistic child having a loud meltdown in a shop — more often applies to boys. Girls more often implode rather than explode: they shut down, fall silent, “freeze,” escape to the bathroom, hide under the table. From the outside it looks less dramatic and is often under-recognised as a sign of overload.

Empathy. Contrary to the simplified stereotype, many girls on the spectrum are very empathic — they sense other people’s moods intensely, sometimes overwhelmingly. This is not in conflict with autism; it is a different kind of difficulty. The issue is not that they do not feel, but that they cannot always process and respond in the way their surroundings expect.

Signs of the spectrum worth attending to in preschool age

This is not a checklist to tick off. A single point proves nothing — most of these behaviours appear from time to time in neurotypical children. What matters is the pattern: how often, how intensely, how much it disrupts daily life.

Signals that, in our preschool work, often turn out years later to have been significant:

Very intense, narrow interests that the child returns to every day and can talk about non-stop.
Difficulty with flexibility: a change in the day’s plan, a rotation of teachers, an unexpected outing — provoke disproportionate reactions.
“One closest friend” and a clear distance from the group. In a larger group the child goes quiet, drifts away, “disappears.”
Exhaustion on returning home — sometimes called after-school restraint collapse — screaming, crying, an emotional collapse after a “perfect” day at preschool.
Sensory reactions: unbearable tags, textures, sounds, lights, smells — or, conversely, an intense seeking of strong stimuli (firm hugging, spinning) in order to self-regulate.
The “little adult”: extraordinary verbal maturity, precise vocabulary, the use of ready-made phrases in situations where other children would speak spontaneously.
High perfectionism and fear of error: bursts of crying or anger over small mistakes.
Rigidity of rituals: the same mug, the same route, the same order of morning tasks. A change provokes collapse.
Eating: a very narrow repertoire, strong avoidance of certain textures.

Once more: on its own, no single one of these behaviours proves anything. But if you see several at once, in different places (home, preschool, at grandparents’), and they persist despite time and support — that is a concrete reason to talk to a specialist.

”The good girl” — the trap we all fall into

There is a certain trap into which we all fall — we who work with small girls — and I have to write about it openly, because it is one of the main reasons we miss the spectrum in girls.

A teacher writes in the observation file: “Zosia is very well-behaved. Quiet, composed, mature beyond her years. Causes no trouble at all. A bit quiet, but that’s surely a virtue.”

From the perspective of the system — all is well. From the child’s perspective — she may be completely exhausted, but is hiding it so well that no one sees. And precisely for that reason she gets no support.

Meanwhile the same set of behaviours in a boy — sitting quietly, not making eye contact, speaking bookishly, knowing one cartoon by heart, unwilling to change his clothes — would be noticed faster, because it does not match social expectations of boys (“he should be lively, energetic”). A mismatch with expectations switches on attention. A match with expectations puts it to sleep.

So an appeal that I repeat to parents and teachers: “causes no trouble” does not mean “needs no support.” Sometimes it means the exact opposite — the child is paying a high price for not making trouble.

The cost of long-term masking

Just because masking is socially effective does not mean it is free. Practice — and a growing body of literature — shows that long, intense masking has a cost. And girls on the spectrum pay that cost very tangibly.

Autistic burnout. A state of deep exhaustion in which previously available strategies stop working. A child who up until now had been “managing” suddenly does not get up for school, loses skills she previously had, locks herself in her room. It most often appears during periods of heightened social demands: the start of school, fourth or fifth grade, the start of secondary school.

Generalised and social anxiety. Living in a state of constant control (“am I behaving well? are they laughing at me? did I say something wrong again?”) is excellent fuel for anxiety disorders. Many adult women on the spectrum were treated for anxiety for years before anyone asked about neurology.

Depression. A constant energetic defeat (“others do this without effort, and I am exhausted after one day”) plus no name for what one is experiencing is a ready recipe for depressive episodes — often in adolescence.

Eating disorders. Among women and girls on the spectrum, we more often than in the general population observe ARFID (avoidant/restrictive food intake disorder), anorexia, and other eating disorders.

Sleep problems. Difficulty falling asleep, nightmares, frequent waking — often the first thing parents bring to the paediatrician. Sometimes the dysregulation lying underneath remains unrecognised for years.

I list these things not to scare anyone — only to honestly show why an early recognition is so important. It is not about a label. It is about a girl not having to spend a decade fighting anxiety or depression before someone notices that underneath she is simply a neurodivergent person, exhausted by the constant work of masking.

What you can do as a parent if you see these signs

The first thing I want to say to parents: a parent’s observation is a valuable source of information, even if it is not a diagnosis. If you have been returning to this thought for months, if “something does not fit” — you do not know what, but you feel it — that is a sufficient reason to begin a conversation.

Concrete steps worth taking first:

Write down what you see. Do not analyse — simply note. Situation, context, the child’s reaction, duration. After two or three weeks of such a journal, patterns become visible.

Ask the preschool teacher directly. Not “is everything all right with my child?” — to which everyone will answer “yes.” Rather: “how does Zosia react to a change of routine? Who does she play with? What does her return to the group look like after a longer solo activity? Has she noticed recurring situations in which she has outbursts or withdraws?” Concrete questions get concrete answers.

Pay special attention to the return from preschool. If she systematically falls apart at five in the afternoon after a “good day” — that is not “boredom” or “hunger.” It is often a sign of regulatory exhaustion.

Build external structure. A day plan in pictures, fixed routines, predictable transitions. For a child on the spectrum, external structure compensates for what she cannot yet do on her own. This is not “spoiling” — it is a prosthesis for executive function. If you are looking for concrete tools, we wrote about a picture schedule as visual support.

Do not try to “treat” behaviours that serve regulation. If the child plays with her hair, rocks, needs her corner — these are not habits to be eradicated. They are techniques she invented herself in order to cope.

And a remark I consider one of the most important: do not try to “fix” the child so that she fits the system. Try, instead, to build her a bridge — of support, structure, tools — that will help her enter the system without losing herself along the way.

Diagnosis in the Polish system

The autism spectrum can be recognised already in a two- or three-year-old, though in practice many girls receive their diagnosis much later.

Educational support — the psychological-pedagogical counselling centre (poradnia psychologiczno-pedagogiczna). This is the first address if you are worried about how your child is functioning in preschool. Public counselling centres are free, though waiting times can be long. They issue opinions and rulings that oblige the institution to implement a specific support plan. The counselling centre does not make a clinical diagnosis but can refer you on.

Clinical diagnosis of the spectrum. A team process: developmental interview with parents, observation of the child (most often with the ADOS-2 tool), questionnaires, sometimes pedagogical and neurological consultations. Public (NFZ) and private pathways are both possible; families often combine the two to shorten waiting times.

Three tips I usually give parents:

Look for a team with experience in girls. Diagnostic work based only on the “classic” picture often releases girls with a negative result despite real difficulties. Ask outright: “do you diagnose girls? are you familiar with the female phenotype of the spectrum?”
If a first diagnosis ruled out the spectrum and you still have doubts — that is no reason to stay silent. That is a reason to get a second opinion. False negatives in girls are a common problem.
If the child simultaneously shows traits of ADHD — look for a team that diagnoses both. The spectrum and ADHD often co-occur (which I write about separately in the text on AuADHD).

A broader conversation about when in general it is worth seeking a diagnosis and what the pathway looks like in the Polish system can be found in the text When to seek a diagnosis for your child.

What to take away

The most important shift in thinking about autism in girls is not medical — it is cognitive. It consists in noticing that the absence of visible problems does not mean their absence. That “polite and quiet” can be the full name of a state in which things are simply hard for the child. That a girl who “does brilliantly at preschool and falls apart at home at five” does not have two personalities — she has one, which has been holding herself together for eight hours with all her strength.

Three sentences I would like to remain after this reading:

First: the spectrum is visible in preschool — also in girls, if we know where to look. “Polite” and “quiet” do not mean “without difficulties.”

Second: girls on the spectrum have always been in our preschools and schools — we just did not see them. This time we understand more. It is worth making use of that.

And third, the most important: a child who receives support earlier does not later need to make up for a dozen years of feeling that something is wrong with her. An earlier recognition does not change who the child is. It changes only one thing, but a fundamental one: how long she has to pretend to be someone else in order to be accepted.

You will find the companion text on how autism often goes hand in hand with ADHD under the title AuADHD — when autism and ADHD co-occur. And if you are interested in how ADHD looks in girls (and why the symptoms are so different from those in boys), I have devoted a separate article to that: ADHD in girls.

About the author

Karolina Anioła — director of Siedmiu Krasnoludków Preschool and Nursery

Karolina Anioła — director of the Siedmiu Krasnoludków Preschool and Nursery in Warsaw’s Saska Kępa. An early-years teacher with over twenty-five years of experience and a certified Social Skills Training (TUS) facilitator. She continually develops her qualifications, combining everyday preschool practice with knowledge of neuropsychological development and emotional regulation in children. Privately, a mother for whom work is a passion.

This text was written for Dzieckologia as a practitioner’s voice — from the perspective of an institution that has been working with neurodivergent children in mixed groups for years.