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

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Yu, Y. Y., Wyman, A., Faulk, C., Fulop, L., Greenberg, R. L., Benecke, R. M., Steinbeck, L. K., Foy, J., Kim, C., Emory, G. O., Fox, E., Storch, E. A., Zampella, C. J., Yerys, B., Schultz, R. T., Parish-Morris, J., Herrington, J., & Clements, C. C. (2026). 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. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-026-07253-z

Publication date: 24 Feb 2026 Added to AutiHub: 4 Oct 2026 Type: Article Article language: English
Publisher source (DOI) Full text OpenAlex source

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Authors

Publication authors
18
Publication authors identified as autistic
1 / 18 (5.6%)
  1. Yuen Yvonne Yu
  2. Austin Wyman *
  3. Calliana Faulk
  4. Lizzy Fulop
  5. Rebecca L. Greenberg
  6. Rachel M. Benecke
  1. Lauren K. Steinbeck
  2. Jessica Foy
  3. Caitlyn Kim
  4. George O. Emory
  5. Elle Fox
  6. Eric A. Storch
  1. Casey J. Zampella
  2. Benjamin Yerys
  3. Robert T Schultz
  4. Julia Parish-Morris
  5. John Herrington
  6. Caitlin C Clements

Abstract

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.

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Cited bibliography overview

These indicators describe the bibliography cited by this publication. An author name is counted each time it appears in one cited reference, so the same person can be counted more than once. Names not yet linked to an author already present in AutiHub are treated as unknown, not as non-autistic. Last computed: 17 Oct 2026 01:28.

Cited references
33
With a DOI
29
Without a DOI, from raw bibliography text
4
3 / 33 (9.1%) cited references include at least one author identified as autistic.
References with data to complete
2 / 33 (6.1%)
References with detected author names
31 / 33 (93.9%)
Without detected author names
2
Without a structured title
2
Without a stable identifier
4
References with raw author names still to review
2
References with external metadata lookup issues
0
These indicators apply to cited references displayed on this page, after technical duplicates have been merged. A reference without a DOI can still support author statistics when a title and author names are available.
Author names detected in the cited bibliography
176
From DOI or external metadata
176
From validated raw bibliography text
0
Raw names already validated
0
Raw names still to review
7
62 / 176 (35.2%) names are linked to an author already present in AutiHub. 114 / 176 (64.8%) names are not yet linked.
Names linked to a person identified as autistic
3 / 176 (1.7%)
Calculated across all author names detected in the cited bibliography. Among names linked to an author already present in AutiHub: 3 / 62 (4.8%). Distinct people identified as autistic: 3 / 159 (1.9%).
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