The Under-Identification of Autism in Females: A Review and Analysis of Sex-Based Scoring Differences Observed in Autism Diagnostic Observation Schedule (ADOS) Module 3
Year: 2026
Type: article
Abstract: PURPOSE: Emerging research highlights sex differences in autism presentation, raising questions about the validity of clinician-administered diagnostic tools like the gold-standard Autism Diagnostic Observation Schedule (ADOS). This study examines whether clinicians’ perceptions, potentially biased toward male-typical presentations, contribute to sex bias in ADOS items and the under-identification of autism in females. METHODS: In a sample of 813 children, multidimensional item response theory graded response models were employed to analyze differential item functioning (DIF) of items in ADOS Module 3 (the version commonly administered to school-aged children with fluent spoken language). RESULTS: Six items showed significant sex bias. On four social communication items, females tended to be underscored, meaning rated as showing fewer autistic features (e.g., more emotion talk) than males with equivalent levels of autism latent traits. In contrast, females tended to be overscored on two items related to restricted or repetitive behaviors and interests (i.e., more finger mannerisms, specific interests, or repetitive behaviors). The impact of sex bias on overall scores was small, ranging from 0.10 to 0.28 points per item, and approximately 0.41 points on the overall test score. CONCLUSION: This analysis joins three previous reports of specific ADOS items that function differently in females than males, with converging evidence identifying two problematic items (D2 and D4). Overall, DIF was small and unlikely to affect ADOS classification. We speculate that the direction and consistency of DIF in social communication items might reflect underlying phenomena (viz., masking, clinician bias) that may relate to female underdiagnosis more generally.
Authors: Yuen Yvonne Yu, Austin Wyman, Calliana J. Faulk, Lizzy J. Fulop, Rebecca L. Greenberg, Rachel M. Benecke, Lauren K. Steinbeck, Jessica Foy, Caitlyn Kim, George O. Emory, Elle Fox, Eric A. Storch, Casey J. Zampella, Benjamin E. Yerys, Robert T. Schultz, Julia Parish-Morris, John D. Herrington, Caitlin C. Clements
Language: English
Subfield: Cognitive Neuroscience
Field: Neuroscience
Domain: Life Sciences
Open Access status: hybrid
Estimated APC paid: $3,190
Awards: Digitizing Human Vocal Interaction to Understand and Diagnose Autism, Graduate Research Fellowship Program (GRFP), Neuroimaging of Top-Down Control and Bottom-Up Processes in Childhood ASD, Immersive Virtual Reality as a Tool to Improve Police Safety in Adolescents and Adults with ASD, Baylor College of Medicine Intellectual and Developmental Disabilities Research Center, Functional Neuroimaging of Attention in Autism, Evaluating a novel approach-avoidance model of repetitive behaviors in autistic adolescents: A multi-method study, Functional Imaging of Flexibility in Autism: Informed by SLC6A4, A longitudinal study identifying psychological and service delivery targets to improve daily living skills and quality of life outcomes among autistic youth exiting high school, The Intellectual and Developmental Disabilities Research Center (IDDRC) at CHOP/Penn, Optimized Affective Computing Measures of Social Processes and Negative Valence in Youth Psychopathology
OpenAlex ID: W7131255149