MHM Magazine

Issue 3 | 2025 | MENTAL HEALTH MATTERS | 25 MHM Interests & Behaviours • Intense interests may focus on socially acceptable topics (e.g., animals, celebrities, books) and so go unnoticed. • Repetitive behaviours may be less visible or channelled into internal routines. • Girls often rely on predictability and structure and become distressed when routines are disrupted. However this distress is not always apparent and may surface later in the day - typically at home time – in what is sometimes referred to as the “four o’ clock meltdown” or “delayed effect”. Interoception, Alexithymia, and ARFID: What’s Beneath the Surface While sensory sensitivities in autism are well known, interoception — the sense of internal bodily states (e.g., hunger, fatigue, pain) — is often overlooked. For many autistic girls, interoceptive signals are muted, delayed, or difficult to interpret. This can manifest as: • Not recognising hunger until irritability escalates • Feeling pain or discomfort without knowing why • Difficulty knowing when to rest, eat, hydrate, or self-soothe These internal disconnects contribute to alexithymia, where a person may feel “off” or overwhelmed but lack the language or awareness to name it. A young woman might say, “I feel weird,” when she is actually anxious, exhausted, or hungry — and not realise it until she reaches breaking point. This also helps explain the development of ARFID (Avoidant/ Restrictive Food Intake Disorder) in many autistic girls. Unlike eating disorders driven by body image, ARFID is sensory- and interoception-driven: • Food aversions may relate to texture, smell, or temperature. • Eating the same foods repeatedly provides predictability and emotional regulation. • Meal-related anxiety often stems from difficulty detecting hunger cues or tolerating new sensations. Recognising these patterns helps shift the narrative from “fussy eater” or “emotionally flat” to someone coping with hidden internal disconnection. Clinical Red Flags That May Present in Primary Care Autistic girls rarely present with “textbook” traits. Instead, they often arrive with secondary mental health or physical complaints: • Anxiety or depression (especially long-standing or resistant to treatment) • Disordered eating or ARFID • OCD-like behaviours tied to routine or sensory needs • Chronic fatigue, headaches, or other somatic symptoms • ADHD traits that only partially explain the picture • History of being bullied, isolated, or socially exhausted • Naivety in relationships or vulnerability to exploitation These features may seem isolated — but often reflect a common neurodevelopmental foundation. The Hidden Cost of Masking Girls often become experts in camouflaging their difficulties to appear socially competent. This masking can be adaptive but carries a heavy emotional cost: • Loss of identity • Social burnout and mental fatigue • Delayed diagnosis and unmet support needs • Higher rates of suicidality, especially in LGBTQIA+ youth (70% of autistics identify as non-heterosexual or gender diverse) Many late-diagnosed women describe feeling like they were “faking a life” without understanding why it was so exhausting. The AQ: A Practical Tool for Early Exploration In time-constrained primary care, tools like the Autism Spectrum Quotient (AQ) can offer a gentle entry point for assessment. What is it? A brief self-report questionnaire that measures autistic traits across five domains: • Social skills • Attention switching • Attention to detail • Communication • Imagination Available in adult, adolescent, and child (parent-report) versions, the AQ isn’t diagnostic — but it can flag the need for a fuller neurodevelopmental assessment. Clinical Tip: For women and girls, even borderline scores should be taken seriously, especially in the presence of masking, anxiety, or co-occurring conditions. Access: www. autismresearchcentre.com What GPs can say (and do) Primary care often provides the first opportunity to explore neurodevelopmental differences — and even small adjustments in language or curiosity can make that exploration more accessible and validating. Here are some approaches that can support clinical conversations and next steps: • Offer the Autism Spectrum Quotient (AQ) as a first-line screening tool to open up further dialogue. • Acknowledge signs of social fatigue, emotional burnout, or sensory overwhelm — even if they’re not immediately visible. • Ask gently about routines, sensory sensitivities, or focused interests when concerns are raised around anxiety, mood, or eating. • Consider referral to a multidisciplinary team (psychologist, psychiatrist, paediatrician) for comprehensive neurodevelopmental assessment. • Share psychoeducation about how autism may present differently in girls and women, particularly the impact of masking and camouflaging. • Use non-pathologising metaphors, for example using the ‘brain as an operating system metaphor’ described below. Strategies don’t require specialist training — just a MHM | 2025 | Volume 12 | Issue 3 | Flying Under the Radar: Identifying Autism in Girls — A Guid for GPs MHM