Linguistic markers of autism in girls: evidence of a "blended phenotype" during storytelling

Abstract

Background: Narrative abilities are linked to social impairment in autism spectrum disorder (ASD), such that reductions in words about cognitive processes (e.g., think, know) are thought to reflect underlying deficits in social cognition, including Theory of Mind. However, research suggests that typically developing (TD) boys and girls tell narratives in sex-specific ways, including differential reliance on cognitive process words. Given that most studies of narration in ASD have been conducted in predominantly male samples, it is possible that prior results showing reduced cognitive processing language in ASD may not generalize to autistic girls. To answer this question, we measured the relative frequency of two kinds of words in stories told by autistic girls and boys: nouns (words that indicate object-oriented storytelling) and cognitive process words (words like think and know that indicate mentalizing or attention to other peoples' internal states).

Methods: One hundred two verbally fluent school-aged children [girls with ASD (N = 21) and TD (N = 19), and boys with ASD (N = 41) and TD (N = 21)] were matched on age, IQ, and maternal education. Children told a story from a sequence of pictures, and word frequencies (nouns, cognitive process words) were compared.

Results: Autistic children of both sexes consistently produced a greater number of nouns than TD controls, indicating object-focused storytelling. There were no sex differences in cognitive process word use in the TD group, but autistic girls produced significantly more cognitive process words than autistic boys, despite comparable autism symptom severity. Thus, autistic girls showed a unique narrative profile that overlapped with autistic boys and typical girls/boys. Noun use correlated significantly with parent reports of social symptom severity in all groups, but cognitive process word use correlated with social ability in boys only.

Conclusion: This study extends prior research on autistic children's storytelling by measuring sex differences in the narratives of a relatively large, well-matched sample of children with and without ASD. Importantly, prior research showing that autistic children use fewer cognitive process words is true for boys only, while object-focused language is a sex-neutral linguistic marker of ASD. These findings suggest that sex-sensitive screening and diagnostic methods-preferably using objective metrics like natural language processing-may be helpful for identifying autistic girls, and could guide the development of future personalized treatment strategies.

Keywords: Autism spectrum disorder; Mentalizing; Narratives; Natural language processing; Sex differences; Social cognition; Storytelling; Word choice.

Fig. 1

“The Fisherman and the Cat” from ADOS-2 Module 3

Fig. 2

Means and standard errors of concrete orientation (a) and cognitive orientation (b) by diagnostic group (ASD, TD) and sex (Male, Female); * p < .05

Fig. 3

Correlations between parent ratings of social ability and (a) concrete orientation (number of nouns), and (b) cognitive orientation (number of cognitive process words) by sex, as measured by SRS-2 T-scores (higher scores indicate greater social impairment)