Suominen, Elna H;
Chen, Calliope A;
Dunlop, Andrew;
Saunders, Rob;
Mandy, William;
(2025)
Sex/Gender Differences in Internalizing Problems of Autistic Children and Young People: A Systematic Review and Meta-Analysis.
Journal of the American Academy of Child & Adolescent Psychiatry
10.1016/j.jaac.2025.10.010.
(In press).
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Abstract
Objective Findings on the presence and direction of a sex/gender difference in internalizing problems for autistic children and young people (CYP) are inconsistent. This systematic review investigated whether autistic boys and girls differ in internalizing problem severity. Method Studies comparing internalizing problems (including depression and anxiety) in autistic boys and girls using validated, continuous measures were included. We searched Medline, Embase, PsycINFO, ASSIA and Web of Science. The Joanna Briggs Institute appraisal checklist for cross-sectional studies was used to assess risk of bias. Random-effects meta-analyses estimated effect size differences for (1) overall internalizing, (2) anxiety symptoms and (3) depression symptoms between autistic boys and girls. Moderation effects of age, IQ, and study methodology were examined through meta-regression. Results We identified 56 studies from 4,093 non-duplicate records (N= 13,410 autistic CYP, girls n=3,657, boys n=9,753). Autistic girls experienced more anxiety symptoms than boys (g= 0.13 [0.03; 0.23], p=0.015). This effect was larger in community (versus clinic) samples (β=0.22, p=0.027), and in samples with higher average age (β= 0.037, p=0.014) and IQ (β=0.013, p=0.013). Autistic girls also showed higher overall internalizing (g=0.10[-0.04; 0.23], p= 0.148) and depression symptoms (g=0.12[-0.01; 0.25], p=0.067), but these differences did not reach significance. Heterogeneity for all pooled sex/gender differences was high. Conclusion In autistic CYP, girls show more anxiety symptoms than boys, and this is most pronounced in older girls and those with higher IQ. We did not find strong evidence for sex/gender differences in overall internalizing problems or depression symptoms. However, the high heterogeneity cautions against drawing conclusions with certainty.
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