Sex differences in autism screening: An examination of the Childhood Autism Spectrum Test–Hebrew version

Abstract

Autism is a neurodevelopmental condition, characterized by altered social communication and repetitive behavior. Typically diagnosed in early childhood, screening and diagnosis at a later age can be challenging, particularly in girls who exhibit a wider range of behaviors and characteristics. This study aimed to examine the Childhood Autism Spectrum Test–Hebrew version in a clinically referred Israeli sample, and to identify items that best discriminate between autistic and non-autistic boys and girls. Parents of 211 autistic (retrospectively reviewed) and 192 non-autistic children, aged 4–12 years, completed the Childhood Autism Spectrum Test–Hebrew version. Results indicated good discriminatory power, with an area under the curve of 0.93. A cutoff of 9 offered optimal sensitivity of 0.93 and specificity of 0.82. The addition of a more focused sex-specific analysis using items that best discriminated autistic from non-autistic boys and girls significantly improved the overall identification rate of autism, particularly in girls. The Childhood Autism Spectrum Test–Hebrew version was positively correlated with the Autism Diagnostic Interview–Revised but not with Autism Diagnostic Observation Schedule-2. Findings underscore the importance of considering sex differences in autism screening and the potential value of sex-specific screening. Future research should focus on replicating these findings in a larger, diverse, prospective study. Lay abstract: Autism is a neurodevelopmental condition, characterized by social communication alterations and restricted, repetitive behaviors. Typically diagnosed in early childhood, screening and diagnosis at a later age can be challenging, particularly in girls who exhibit a wider range of behaviors and characteristics. Our study set out to examine the effectiveness of the Hebrew translation of the Childhood Autism Spectrum Test, a parent report questionnaire, in identifying these diverse characteristics of autism within an Israeli sample of boys and girls. We examined parent reports on 403 (211 autistic, 192 non-autistic) children, aged 4–12 years. Results revealed the Childhood Autism Spectrum Test–Hebrew version was a valuable tool in differentiating between autistic and typically developing children, correctly identifying 93% of children with autism and 82% of typically developing children. In addition, specific items of the Childhood Autism Spectrum Test–Hebrew version were particularly useful in differentiating between autistic and non-autistic boys and autistic and non-autistic girls. Using these items, in addition to the overall score of the questionnaire, increased the correct identification of children as autistic or typically developing, especially in girls. The Childhood Autism Spectrum Test–Hebrew version test results corresponded well with the Autism Diagnostic Interview–Revised, which relies on parental input, but not with the clinician-administered Autism Diagnostic Observation Schedule-2. Our findings highlight the potential benefits of gender-specific tools to better support correct identification of autism in boys and in girls. More research is recommended to further explore these gender differences and to validate our findings with a larger, diverse group.