Gender differences between adolescents with autism in emergency psychiatry

Abstract

Adolescents, particularly those with autism spectrum disorders, increasingly use psychiatric emergency services. Such risk is further greater in girls. Available knowledge on young people with autism during crises lacks understanding of gender differences and of differences between typically developing adolescents and adolescents with autism. After psychiatric emergency consultations, we therefore compared the symptomatology and comorbidity of girls and boys with autism, and also to their typically developing male and female counterparts. We used registry data (2009–2017) on 1378 adolescents aged 12–18 years referred for urgent consultation to mobile psychiatric emergency services. This showed an increase in diagnoses of autism spectrum disorder from 7.9% in 2009 to 18.1% in 2016; autistic girls showed a steeper increase than autistic boys. A higher percentage of girls than boys with autism presented with comorbid anxiety disorders and a higher risk of suicide or self-harm, while the persistence of their complaints over time was rated lower. Adolescents with autism experienced more severe impairment in overall functioning, while being diagnosed less often with comorbid disorders as compared to typically developing adolescents. Outpatient care for autistic youth should include easy access to specialized professionals to help young people with autism cope with the challenges of adolescence.

Lay abstract

Among adolescents seen for psychiatric emergency consultation, the percentage of adolescents with autism is increasing over the years. This applies even more to girls than to boys. We collected data of 1378 adolescents aged 12–18 years who were seen for urgent consultation by mobile psychiatric emergency services in the Netherlands. Among these, there were 64 autistic girls and 125 autistic boys. We wanted to know more about differences in problems between autistic and typical developing adolescents in crisis, both to prevent crisis and to improve services. The percentage of adolescents with autism increased over the years studied. Autistic adolescents experienced more severe impairment in functioning compared to typically developing adolescents. Compared to other adolescents, both boys and girls on the autism spectrum were diagnosed less frequently with mood disorders, behavioral disorders, relational problems, and abuse. Autistic girls had a higher suicide risk and suffered more often from anxiety disorders than autistic boys, while autistic boys had a longer history of problems. Outpatient care for children with autism should include easy access to specialized professionals who aim to reduce anxiety and help young people with autism to cope with the challenges of adolescence. Because possibly signs were missed during the emergency consultation, we recommend that as part of the routine procedure in crisis situations adolescents with autism are asked about mood and behavioral problems explicitly, as well as about negative life events.

Keywords

adolescents autism spectrum disorders child psychiatry crisis emergency mental health services gender differences sex differences

Introduction

Several studies have reported that young people with autism spectrum disorders (ASDs) make greater use of emergency departments (EDs) than young people without autism (e.g. Iannuzzi et al., 2015; Kalb et al., 2012; Lytle et al., 2018). A recent study using parent reports on 462 individuals who were enrolled in the Interactive Autism Network found that approximately one-third of children, adolescents and young adults with autism had experienced a mental health crisis within the last 3 months (Vasa et al., 2020). A systematic review of ED use reported that children and adolescents with autism more frequently present with externalizing problems and psychotic symptoms than children and adolescents without autism; they also need to be hospitalized more often (Lytle et al., 2018). In the United States, a study that used the healthcare claims data of over 50,000 individuals aged between 12 and 21 found an annual sequential increase of ED visits by male and in female adolescents with autism, while the percentage of adolescents without autism visiting the ED remained stable (Liu et al., 2017). Another study in the United States, which was based on healthcare claims, found that ED use by girls with autism was higher than ED use by boys with autism (Liu et al., 2019).

Relative to their typically developing (TD) peers, boys and girls with autism have high rates of comorbid mental health problems (Simonoff et al., 2008; Tsai, 2014), and experience a higher frequency of negative life events, bullying, and trauma (Hoover & Kaufman, 2018; Zablotsky et al., 2014). A systematic review of studies that examined suicidality in autism found that the risk of suicide attempts and ideation in people with autism is increased compared to TD people, with an odds ratio (OR) of 1.7 in a recent meta-analysis (Zahid & Upthegrove, 2017). It is therefore likely that more young people with autism present at ED than young TD people do.

In recent years, the scope of research on how boys and girls with autism differ in their clinical presentation has increased (Dworzynski et al., 2012; Kirkovski et al., 2013; Sedgewick et al., 2016). In 2017, over 100 experienced clinicians were interviewed on their opinions and perceptions of the relative severity of symptoms in girls and boys with autism at different points during development (Jamison et al., 2017). In the view of these clinicians, girls experienced more problems during adolescence, and had more severe psychiatric comorbidities than adolescent boys. This is supported by the findings of a birth cohort study (Mandy et al., 2018). They found gender-specific trajectories of autistic social impairment, with girls more likely than boys to experience an escalation of autistic features during early- and mid-adolescence. In 2017, 20 studies were included in a systematic review of studies comparing the gender differences of young people with autism with those of young TD people (Hull et al., 2017). With regard to challenges that come with social interaction, the gender differences in young people with autism varied according to the ages of the participants: these differences were found in the studies including adolescents in their sample, but not in studies, which included either children or adults only. The review also concluded that the impact of autism may differ between boys and girls with autism: compared to boys with autism girls with autism have better task switching and cognitive flexibility abilities and this may influence their phenotype.

The aim of this study was to investigate changes in the prevalence of autism in adolescents 12–18 years in the ED over time. Next, we aimed to establish gender differences with regard to demographic, clinical, and contextual characteristics (the latter being defined as external factors related to the emergency consultation) in order to inform clinicians about characteristics of both adolescent boys and girls with autism in ED consultation.

Method

Setting

The study was conducted in two urban areas in the Netherlands: Apeldoorn (approximate population 700,000) and the Greater Rotterdam region (approximate population 1.2 million).

In both regions, an outpatient psychiatric emergency service is responsible 24/7 for assessing any patients referred to them. Most patients are referred by telephone by general practitioners, mental healthcare workers, police, and the EDs at general hospitals. The primary tasks of the outpatient psychiatric emergency service are triage and the subsequent referral of psychiatric emergency patients to other psychiatric services. The staff at the emergency services comprises community psychiatric nurses, physicians, and psychiatrists who all had training to generate psychiatric diagnosis in emergency patients. They determine on the basis of the information obtained by telephone whether an acute assessment is necessary. If so, patients of all ages are examined at the patient’s location by a team consisting of a nurse and a physician or psychiatrist. If the physician is not a psychiatrist, a psychiatrist is consulted by telephone. As police in the Netherlands are not permitted to take psychiatrically disturbed children to a psychiatric hospital, they usually ask for psychiatric emergency-service staff to assess them at the police station. In all situations, at a police station or elsewhere, the psychiatric emergency service assesses the patient, and, when applicable, their significant others and tries to resolve the crisis situation, preferably without hospitalization.

Patients

Data for the period from 1 January 2009 to 1 January 2017 were extracted from the records of the mobile psychiatric emergency services in the two urban areas. We included emergencies involving adolescents aged 12–18 years who had been referred for urgent consultation. In patients with a prior emergency consultation, which was defined as a repeated emergency assessment within 12 months, we excluded the repeat visits within 12 months. Members of the autistic and autism communities were not involved in the study.

The data were provided anonymously, and the authorized Medical Ethics Committee at Erasmus University Medical Center confirmed that the Medical Research Involving Human Subjects Act (known by its Dutch acronym, WMO) did not apply to this study, and thus that no informed consent was required.

Data extraction

After each emergency consultation, the nurse and the physician or psychiatrist filled out patient record forms and collected information on patient, contextual, and clinical variables. Data were processed in accordance with the General Data Protection Regulation.

Demographic characteristics included age, gender, and living situation (two-parent family, single-parent family, “other” and unknown). Examples of “other” living situations are: homelessness, living on their own, in sheltered housing, or in an institute. Specific data on socioeconomic status and educational attainment levels were not recorded. Contextual characteristics included reasons for referral (defined as danger to self, danger to others, psychotic symptoms, anxiety/depressive symptoms, and “other”); “does the family want admission?” (yes, no or unknown); and being in regular outpatient care (ROPC) (defined as currently being in outpatient psychiatric care (yes or no)).

Clinical characteristics comprised Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) classifications, recent drug or alcohol use (yes/no/unknown), and severity of problems. The DSM-IV Axis I classifications were grouped into nine categories: ASDs, attention-deficit disorders, mood disorders, anxiety disorders, psychotic-spectrum disorders, impulse-control disorders, behavioral disorders, relational problems and abuse, and “other.” A disorder was registered as being present if it was classified on Axis I; for an individual patient more than one diagnostic category could be noted. Axis II classification was registered, of which we used only mental retardation (yes or no); this was registered by the staff of the psychiatric emergency service if sufficient information was available or if a patient already had a diagnosis of mental retardation.

Severity of specific problems was assessed using the Global Assessment of Functioning (GAF) scale and the Severity of Psychiatric Illness Scale (SPI, Lyons 1998; Dutch version by Mulder et al., 2005). The SPI is a decision-support tool for assessing the need for services. It provides a structured description of the severity of psychopathology and of possible complications regarding the disorder and regarding treatment. It has 14 items: suicide risk, danger to others, severity of symptoms, self-care ability, substance abuse or dependence, medical complications, family disruption, vocational impairment, residential instability, lack of motivation for treatment, lack of medical compliance, awareness of illness, lack of family involvement, and persistence of complaints. These items were scored on a four-point scale from 0 (no problem) to 3 (severe problem). SPI ratings were dichotomized for the analyses: no/small problem and moderate/severe problem.

The outcome of the emergency consultations was also available. Intervention was defined as voluntary admission, compulsory admission, and no admission.

Analyses

Descriptive statistics were used to summarize the demographic, contextual, and clinical characteristics of girls and boys with autism, and of girls and boys without autism.

Multiple logistic regression analysis was used to identify variables specific to the female and male profiles of adolescents with ASD seen for psychiatric emergency consultation. Logistic regression models were further applied to identify variables that differentiated between the two groups of girls and boys seen for psychiatric emergency consultation: those with and those without a diagnosis of autism. All demographic, contextual, and clinical variables were initially included as covariates but only reported when they contributed to the final model. When appropriate, scores were centered prior to analysis. Following Hosmer and Lemeshow (2000), we based variable selection on a stepwise procedure with p < 0.25 as the entry level and p > 0.05 as the removal level. Model fit was assessed using Area-Under-the-Curve statistics and the Hosmer–Lemeshow goodness-of-fit test. In the final model, OR estimates and their corresponding 95% confidence intervals were calculated. All statistical analyses were performed using SPSS version 24.

Results

Prevalence over time

A diagnosis of autism was registered in 189 of 1378 emergency consultations (13.7%). Over time, the yearly percentage of patients diagnosed with autism rose from 7.9% in 2009 to 18.1% in 2016. The number of diagnoses increased in both gender groups, rising from 3.8% to 11.1% for girls (an increase of 290%), and from 14.9% to 30.8% for boys (an increase of 200%).

Differences between girls and boys with autism

The first and second columns of Table 1 contrast the characteristics of girls and boys with autism. In both sexes, the most frequent reason for referral was risk of suicide or self-harm. The percentage of boys with autism who had been referred for being a danger to others was 25.6% (n = 32), more than twice that of girls with autism (10.9%, n = 7).

Table 1.

Patient and contextual characteristics, and admission rates: separate means, totals, frequencies, and SDs for girls and boys aged 12–18 years who were seen for the first time for emergency consultation and were either diagnosed with autism or were not diagnosed with autism (non-ASD).

	ASD girls, n = 64	ASD boys, n = 125	Non-ASD girls, n = 787	Non-ASD boys, n = 402
Mean age (SD)	15.5 (1.5)	15.4 (1.4)	15.5 (1.5)	15.5 (1.6)
Family wanted admission, n (%)	28 (43.8)	52 (41.6)	198 (25.2)	116 (28.9)
Living situation, n (%)
With two parents	30 (46.9)	58 (46.4)	409 (52.0)	209 (52.0)
With single parent	10 (15.6)	34 (27.2)	194 (24.7)	98 (24.4)
Other	16 (25.0)	19 (15.2)	113 (14.4)	61 (15.2)
Unknown	8 (12.5)	14 (11.2)	71 (9.0)	34 (8.5)
Main reason for referral, n (%)
Risk of suicide/self-harm	39 (60.9)	60 (48.0)	590 (75.0)	220 (54.7)
Danger to others	7 (10.9)	32 (25.6)	31 (3.9)	55 (13.7)
Psychotic symptoms	6 (9.4)	13 (10.4)	44 (5.6)	55 (13.7)
Anxiety/depressive symptoms	3 (4.7)	3 (2.4)	33 (4.2)	18 (4.5)
Other	9 (14.1)	17 (13.6)	89 (11.3)	54 (13.4)
In ROPC, n (%)	48 (75.0)	88 (70.4)	444 (56.4)	202 (50.2)
Intervention, n (%)
Voluntary admission	10 (15.6)	20 (16.0)	85 (10.8)	43 (10.7)
Compulsory admission	6 (9.4)	7 (5.6)	34 (4.3)	26 (6.5)

SD: standard deviation; ASD: autism spectrum disorder; ROPC: regular outpatient care.

The first and second columns of Table 2 contrast the clinical characteristics of girls and boys with autism. The two sexes had different patterns of comorbidity. Compared to boys with autism, a higher percentage of girls presented with anxiety disorders, while a lower percentage presented with behavioral problems.

Table 2.

Clinical characteristics: separate means, totals, frequencies, and SDs for girls and boys aged 12–18 years who were seen for the first time for emergency consultation and were either diagnosed with autism or were not diagnosed with autism (non-ASD).

	ASD girls, n = 64	ASD boys, n = 125	Non-ASD girls, n = 787	Non-ASD boys, n = 402
DSM-IV Axis I, n (%)
Anxiety disorders	12 (18.8)	5 (4.0)	113 (14.4)	41 (10.2)
Mood disorders	9 (14.1)	21 (16.8)	217 (27.6)	90 (22.4)
ADHD	7 (10.9)	21 (16.8)	39 (5.0)	42 (10.4)
Impulse-control disorders	7 (10.9)	6 (4.8)	31 (3.9)	28 (7.0)
Relational problems and abuse	5 (7.8)	9 (7.2)	186 (23.6)	80 (19.9)
Behavioral disorder	4 (6.3)	21 (16.8)	129 (16.4)	91 (22.6)
Psychotic spectrum disorders	4 (6.3)	11 (8.8)	35 (4.4)	55 (13.7)
Other axis 1 disorder	7 (10.9)	21 (16.8)	291 (37.0)	125 (31.1)
Mental retardation, n (%)	4 (6.3)	5 (4.0)	33 (4.2)	15 (3.7)
Recent alcohol use, n (%)	3 (4.7)	14 (11.2)	83 (10.5)	70 (17.4)
Recent drug use, n (%)	3 (4.7)	12 (9.6)	79 (10.0)	73 (18.2)
Recent drug and/or alcohol use, n (%)	6 (9.4)	20 (16.0)	124 (15.8)	106 (26.4)
Mean GAF score (SD)	41.6 (10.9)	44.0 (10.4)	47.3 (10.8)	46.7 (11.6)
Moderate or severe ratings on the SPI, n (%)
Suicide risk	21 (32.8)	26 (20.8)	297 (37.7)	115 (28.6)
Danger to others	6 (9.4)	26 (20.8)	47 (6.0)	59 (14.7)
Severity of symptoms	51 (79.7)	105 (84.0)	489 (62.1)	257 (63.9)
Disturbance of self-care ability	6 (9.4)	17 (13.6)	56 (7.1)	43 (10.7)
Substance abuse or dependence 1 (1.6)	8 (6.4)	57 (7.2)	53 (13.2)
Medical complications	6 (9.4)	7 (5.6)	46 (5.8)	19 (4.7)
Family disruption	28 (43.8)	68 (54.4)	390 (49.6)	206 (51.2)
Vocational impairment	30 (46.9)	58 (46.4)	235 (29.9)	140 (34.8)
Residential instability	13 (20.3)	26 (20.8)	120 (15.2)	76 (18.9)
Lack of motivation for treatment	15 (23.4)	41 (32.8)	212 (26.9)	135 (33.6)
Lack of medical compliance	13 (20.3)	32 (25.6)	145 (18.4)	105 (26.1)
Lack of awareness of illness	33 (51.6)	81 (64.8)	391 (49.7)	218 (54.2)
Lack of family involvement	2 (3.1)	9 (7.2)	59 (7.5)	43 (10.7)
Persistence of complaints	30 (46.9)	92 (73.6)	398 (50.6)	206 (51.2)

SD: standard deviation; ASD: autism spectrum disorder; ADHD: attention-deficit hyperactivity disorder; GAF: Global Assessment of Functioning; SPI: Severity of Psychiatric Illness Scale.

Table 3 shows the final model of logistic regression analyses for demographic, contextual, and clinical characteristics associated with gender in adolescents with autism seen for psychiatric emergency consultation. A DSM classification of an anxiety disorder and severe or moderate SPI scores for suicide risk and for persistence of complaints were found to contribute to the model. A classification of an anxiety disorder (OR = 5.79; 95% confidence interval (CI) = 1.81–18.55) and severe or moderate SPI scores for suicide risk (OR = 2.34; 95% CI = 1.13–5.20) predicted female gender. Severe or moderate SPI scores for persistence of complaints (OR = 0.26; 95% CI = 0.13–0.52) predicted male gender.

Table 3.

Factors associated with gender (logistic regression) in autism youth (12 plus) seen for the first time for psychiatric emergency consultation (n = 189). Boys are reference group.

	Beta (SE)	Wald	df	Significance	95% CI for Exp(B)
	Beta (SE)	Wald	df	Significance	Lower	Exp(B)	Upper
Constant	−0.25 (0.26)	0.921	1	0.337		0.78
DSM-IV Axis I
Anxiety disorder	1.76 (0.59)	8.742	1	0.003	1.81	5.79	18.55
SPI moderate/severe
Suicide risk	0.89 (0.39)	5.193	1	0.023	1.13	2.43	5.20
Persistence of complaints	−1.35 (0.35)	14.755	1	0.000	0.13	0.26	0.52

SE: standard error; df = degree of freedom; CI: confidence interval; SPI: Severity of Psychiatric Illness Scale R² = 0.20 (Nagelkerke); AUC = 0.72, 95% CI = 0.64–0.80, p < 0.0001; Hosmer–Lemeshow goodness of fit = 0.226, p = 0.893.

Differences between girls with and without autism

The first and third columns of Table 1 contrast the demographic and contextual characteristics of the girls with a diagnosis of autism with those of the girls without a diagnosis of autism. Relative to their peers without autism, a higher percentage of girls with autism were referred due to danger to others, and a lower percentage was referred due to risk of suicide or self-harm. Similarly, a higher percentage of girls with autism received outpatient care in the period before the emergency consultation, and in 43.8% (n = 28), admission was requested by the families of girls with autism, compared to 25.2% (n = 198) by the families of girls without autism.

The first and third columns of Table 2 contrast the clinical characteristics of girls with autism with the characteristics of those without autism. While a lower percentage of girls with autism presented with mood disorders, behavioral disorders or relational problems and abuse, a higher percentage of them presented with attention-deficit hyperactivity disorder (ADHD) and impulse-control disorders. Girls with autism also experienced more severe impairments in functioning, and a higher percentage of girls with autism had moderate/severe SPI scores on severity of psychiatric symptoms and vocational impairment.

Table 4 shows the final model of logistic regression analyses for demographic, contextual, and clinical characteristics associated with a diagnosis of autism in girls seen for emergency consultations. Poorer global functioning, DSM-IV classifications of mood disorders, behavioral disorders or relational problems and abuse, and receiving outpatient care were found to contribute to the model. Receiving outpatient care (OR = 2.62; 95% CI = 1.44–4.78) predicted a diagnosis of autism. Conversely, having better global functioning (OR = 0.95; 95% CI = 0.93–0.98), and DSM-IV classifications of relational problems and abuse (OR = 0.32; 95% CI = 0.12–0.82), mood disorders (OR = 0.26; 95% CI = 0.12–0.55), and behavioral disorders (OR = 0.24; 95% CI = 0.080–0.68) were associated with lower odds for an autism diagnosis.

Table 4.

Factors associated with autism in girls (12 plus) who were seen for the first time for psychiatric emergency consultation (n = 851). Girls without autism are the reference group.

	Beta (SE)	Wald	df	Significance	95% CI for Exp(B)
	Beta (SE)	Wald	df	Significance	Lower	Exp(B)	Upper
Constant	−0.40 (0.57)	2.991	1	0.084		0.45
In ROPC	0.96 (0.31)	9.602	1	0.002	1.44	2.62	4.78
GAF score	−0.05 (0.01)	17.669	1	0.000	0.93	0.95	0.98
DSM-IV Axis I
Relational problems and abuse	−1.15 (0.48)	5.617	1	0.018	0.12	0.32	0.82
Mood disorder	−1.35 (0.38)	12.641	1	0.000	0.12	0.26	0.55
Behavioral disorder	−1.43 (0.54)	7.348	1	0.007	0.08	0.24	0.68

SE: standard error; df: degree of freedom; CI: confidence interval; GAF: Global Assessment of Functioning; ROPC: regular outpatient care R² = 0.15 (Nagelkerke); AUC = 0.76, 95% CI = 0.70–0.82, p < 0.0001; Hosmer–Lemeshow goodness of fit = 3.674, p = 0.885.

Differences between boys with and without autism

The second and fourth columns of Table 1 contrast the demographic and contextual characteristics of the boys with a diagnosis of autism with those of the boys without such a diagnosis. Compared to their peers without autism, a higher percentage of boys with autism were referred because of danger to others, received outpatient care in the period before the emergency consultation, and had families who requested admission.

The second and fourth columns of Table 2 contrast the clinical characteristics of boys with autism and those without autism. A lower percentage of boys with autism presented with anxiety disorders, relational problems, or drug and alcohol abuse than boys without autism. Conversely, they experienced more severe impairment in functioning, and a higher percentage of them had severe or moderate SPI scores on severity of psychiatric symptoms, vocational impairment, lack of awareness of illness, and persistence of complaints.

Table 5 shows the final model of logistic regression analyses for demographic, contextual, and clinical characteristics associated with autism in boys seen for emergency consultations. Receiving outpatient care, DSM-IV classifications of behavioral disorders, mood disorders, relational problems and abuse or anxiety disorders, and having severe or moderate SPI scores on severity of symptoms, persistence of complaints, and substance abuse or dependence were found to contribute to the model. Receiving outpatient care (OR = 2.24; 95% CI = 1.41–3.55) and having severe or moderate SPI scores on severity of symptoms (OR = 2.29; 95% CI = 1.30–4.02) or persistence of complaints (OR = 2.19; 95% CI = 1.35–3.55) were associated with a diagnosis of autism. Conversely, DSM-IV classifications of behavioral disorders (OR = 0.48; 95% CI = 0.27–0.85), mood disorders (OR = 0.44; 95% CI = 0.25–0.79), relational problems and abuse (OR = 0.35; 95% CI = 0.16–0.74), or anxiety disorders (OR = 0.25; 95% CI = 0.09–0.68), and severe or moderate SPI scores on substance abuse or dependence (OR = 0.37; 95% CI = 0.16–0.83) were associated with lower odds for an autism diagnosis.

Table 5.

Factors associated with autism in boys (12 plus) who were seen for the first time for psychiatric emergency consultation (n = 851). Boys without autism are the reference group.

	Beta (SE)	Wald	df	Significance	95% CI for Exp(B)
	Beta (SE)	Wald	df	Significance	Lower	Exp(B)	Upper
Constant	−2.14 (0.31)	47.188	1	0.000		0.12
In ROPC	0.80 (0.24)	11.586	1	0.001	1.41	2.24	3.55
DSM-IV Axis I
Behavioral disorder	−0.74 (0.29)	6.252	1	0.012	0.27	0.48	0.85
Mood disorder	−0.81 (0.29)	7.713	1	0.005	0.25	0.44	0.79
Relational problems and abuse	−1.06 (0.39)	7.467	1	0.006	0.16	0.35	0.74
Anxiety disorder	−1.37 (0.51)	7.335	1	0.007	0.09	0.25	0.68
Moderate or severe ratings on the SPI
Severity of symptoms	0.83 (0.29)	8.210	1	0.004	1.30	2.29	4.02
Persistence of complaints	0.78 (0.25)	10.137	1	0.001	1.35	2.19	3.55
Substance abuse or dependence	−1.00 (0.41)	5.852	1	0.016	0.16	0.37	0.83

SE: standard error; df: degree of freedom; CI: confidence interval; ROPC: regular outpatient care R² = 0.20 (Nagelkerke); AUC = 0.74, 95% CI = 0.69–0.79, p < 0.0001; Hosmer–Lemeshow goodness of fit = 7.383, p = 0.390.

Discussion

In the period 2009–2016, we found a relative increase over time in the prevalence of boys and girls with autism seen by the mobile psychiatric emergency services for psychiatric emergency consultation. Girls with autism showed a steeper increase than boys with autism. In emergency situations, a higher percentage of girls than boys with autism presented with comorbid anxiety disorders and a higher risk of suicide or self-harm, while the persistence of their complaints over time was rated lower. We also found that boys and girls with autism experienced more severe impairment in overall functioning, compared to adolescents without autism, while being diagnosed less often with comorbid internalizing or externalizing disorders as compared to adolescents without autism.

Our finding of a rising percentage of girls and boys with a diagnosis of autism seen for psychiatric emergency consultation is in line with that found in other studies (Liu et al., 2017, 2019). In a study based on health care claims, the higher ED utilization by young people with autism could not be explained by the increased identification of autism (Liu et al., 2017). Other studies suggest that adolescents with autism present more often for emergency psychiatric care due to difficulty in accessing regular mental health services (Carbone et al., 2013; Chiri & Warfield, 2012). In this study, however, over 70% of the adolescents with autism had received regular outpatient care before their emergency consultation. Similarly, Mandell et al. (2019) found that increased outpatient-service utilization in young people with autism did not reduce the risk of psychiatric ED visits.

We found that boys and girls with autism experienced more severe impairment in overall functioning than peers who had not been diagnosed with autism, so in this study, the referrals to the ED of adolescents with autism were not inappropriate or made for non-urgent reasons (Cohen-Silver et al., 2014). An additional explanation for the relative increase in the prevalence of psychiatric emergency consultations involving boys and girls with a diagnosis of autism might be that the quality and intensity of services delivered is not fitting the serious and increasing needs of young people with autism. In this study in 2006, a four times higher percentage of boys than girls were diagnosed with autism, which is in line with the overall gender difference in prevalence of autism. In 2016, the risk of psychiatric emergencies involving girls with autism has increased more than that of boys. During adolescence, more girls with autism than boys with autism experience increase in social anxiety (Varela et al., 2020). Girls with autism are particularly liable to new challenges related to puberty—a time when relationships with peers become more complex. Unlike conversations between boys, those between girls become more interpersonally focused, and social activities between girls tend to rely more on sharing interests (Jamison et al., 2017; Raffaelli & Duckett, 1989). Underneath their sociable behavior, adolescent girls with autism often experience high levels of stress and anxiety, as they develop more insight into the social limitations linked with the disorder, and have to work hard to maintain a mask (Varela et al., 2020; Young et al., 2018). The great effort they need to compensate for their difficulties may cause exhaustion and distress (Bargiela et al., 2016) that without timely identification and help may lead to more frequent emergency psychiatry referrals.

This study aimed to establish gender differences in the clinical presentation of adolescents with autism who are seen for psychiatric emergency consultation. We found that, in an emergency situation, a higher percentage of girls than boys with autism presented with comorbid anxiety disorders and with a relatively higher risk of suicide or self-harm. Although the literature on gender differences in comorbid depression and anxiety in children of various ages with autism shows diverging results and does not describe emergency situations (Gotham et al., 2015; Hull et al., 2017; Kirsch et al., 2019), it is possible that especially girls with comorbid anxiety disorders fall into crisis, or, in an emergency situation, that girls with autism show the anxiety that they manage to keep concealed in other situations.

Our finding that the persistence of symptoms in girls with autism was generally rated lower than that of boys with autism is consistent with the literature. Usually, the recognition of autism is later in girls, especially in those with good verbal abilities and those whose intelligence quotient (IQ) is average or above average (Andersson et al., 2013; Dworzynski et al., 2012; Giarelli et al., 2010; Rynkiewicz & Łucka, 2015). At younger ages, boys more than girls with autism present with externalizing problems, causing their parents to seek help. As girls have better socio-communication skills, the challenges younger girls with autism experience in social settings are less visible than those of their male counterparts (Kirkovski et al., 2013; Lai et al., 2015; Rynkiewicz et al., 2016).

Surprisingly, we found that, in emergency situations, a lower percentage of boys and girls with autism were diagnosed with comorbid mood disorders, behavioral disorders, and relational problems and abuse than peers without an autism diagnosis. Studies comparing internalizing problems between children with autism and TD children—whether from the general population or clinically referred, but not in an emergency situation—consistently demonstrate that internalizing problems are more severe in children with autism (e.g. Kim et al., 2000; Simonoff et al., 2008). Also, a systematic review of ED use by children and adolescents with autism found that they presented with externalizing problems more than children and adolescents without ASD (Lytle et al., 2018).

Children with autism also have a greater risk of maltreatment and physical and sexual abuse (McDonnell et al., 2018). At school, despite their efforts to overcome difficulties such as understanding the subtlety of nonverbal communication, adolescents with autism may react inadequately in ways that elicit teasing and bullying, and thus lead to even greater anxiety and isolation. For example, missing flirtatious signals may lead to unsolicited physical abuse and exploitation (Cridland et al., 2014). There are several explanations for the lower comorbidity rates we found. A possible explanation is that depression may be harder to recognize in an emergency situation, not only because the symptoms of autism mask some of the core features of depression, but also because adolescents with autism may under-report their depressive symptoms due to difficulties in communicating about feelings face-to-face. Behavioral problems are sometimes attributed to autism, and the emergency consultation may have been too short for adolescents with autism to open up about their problems to a strange person. It is therefore possible that signs of relational problems and abuse are missed during an emergency consultation.

The differences between girls with and without an autism diagnosis should be interpreted with some caution. Since autism in girls is often unrecognized, it is to be expected that some girls in the group without an autism diagnosis nonetheless had autism. A diagnosis of autism depends on two factors: the difficulties parents perceive in a daughter, and the way those difficulties and the symptoms the girl exhibits are interpreted by healthcare professionals. Lai et al. (2011) noted that although many of the women involved in their study failed to meet the cut-off criteria for the Autism Diagnostic Observation Schedule (ADOS, Lord et al., 2000)—which is considered to be the gold standard—they met the criteria for clinical diagnosis determined by experienced clinicians and the Autism Diagnostic Interview–Revised (ADI-R, Lord et al., 1994). The following is possible: even if girls without a diagnosis of autism had previously been assessed for autism, but had not been found to have autism, the exhaustion caused by “camouflaging” their symptoms finally caused a crisis.

Strengths and limitations

This study is the first to compare not only girls with autism with boys with autism, but also girls and boys with and without autism who attended psychiatric emergency consultation. Our findings might improve understanding of psychiatric emergencies involving autistic boys and girls, and may guide the development of ways to prevent and handle crisis situations in young people with autism.

However, this study also had five main limitations. First, the diagnosis of autism and comorbidity was based on psychiatric history or a non-standardized clinical interview during psychiatric emergency consultation. In the psychiatric emergency services, the use of a standardized evaluation protocol, such as the ADOS (Lord et al., 2000) or the ADI-R (Lord et al., 1994)—which are considered the gold standard—is not feasible. In the emergency setting, it is likely that comorbid disorders may have been missed, especially in youth with autism. Second, we did not have data on the reliability of both the GAF scale and the SPI. Both instruments have been found reliable in an emergency situation in other studies, in an adult population, however.

Third, no information was available on the specific treatment offered before the emergency consultation; the mental health services attended by children with autism can range from school counselors to mental healthcare provided by autism specialists. Fourth, since we only used data from the psychiatric emergency service, and did not have access to other ED data, we most likely missed data of youth with psychiatric emergencies masked by physical health problems. Finally, as stated in section “Discussion,” since autism in girls is often unrecognized, it is to be expected that some girls in the group without a diagnosis of autism nonetheless had autism.

Clinical implications

Although a majority were already receiving outpatient mental health care, we found an increase over time in psychiatric emergencies in adolescents with autism and severe problems. This may have been due to better recognition of autism by staff at the psychiatric emergency services, or to a real increase caused by more crisis situations among youngsters with autism. In our view, as adolescence proceeds, outpatient care for children with autism should include easy access to specialized professionals who aim to reduce anxiety and help young people with autism to cope with the new challenges of adolescence. Behavioral interventions should be considered at an early stage to prevent crisis situations. Our findings suggest in particular that a full assessment of girls with autism should include a careful examination of anxiety problems.

Staff at the psychiatric emergency services should also be aware that many adolescents with autism only reveal their difficulties when asked explicitly. As part of the routine in crisis situations, we recommend that adolescents with autism are screened for internalizing and externalizing comorbidity, relational problems, abuse, or problems such as cyber-bullying. This may help provide targets for follow-up treatment. A possible topic for future research is to establish whether the risk of crisis situations, suicidality, and substance-abuse problems later in life would be reduced by a greater focus on comorbidity and relational problems during follow-up of young people with autism.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

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