Understanding and Supporting Puberty in Autistic Girls and Boys
Blythe A. Corbett, Ph.D., discusses her lab’s research on puberty, adolescence, and mental health in autistic individuals. She emphasizes puberty as a period of significant biological maturation involving several physical, biological, hormonal, and social factors. The speaker details her lab’s latest research on pubertal onset, mental health, hormonal changes, and gender identity in autistic young people compared to allistic (non-autistic) groups. Corbett repeatedly emphasizes how puberty can be particularly complex for autistic youth (especially those assigned female at birth), who are already vulnerable to change and stress. She summarizes the presentation and underscores the importance of exploring how puberty’s hormonal, psychological, and social changes interact with the autism phenotype before the Q&A.
Adolescence & puberty in autism
Corbett describes autism as a neurodevelopmental condition characterized by differences in social communication (e.g., social-emotional reciprocity, non-verbal communication) and restricted, repetitive patterns of behavior, interests, or activities (e.g., insistence on sameness, sensory sensitivities) (01:35). Adolescence, she explains, is a transformative stage characterized by significant psychological, social, emotional, and hormonal shifts, typically spanning ages 10 to 24. Within this broader period of adolescence, puberty specifically marks the biological maturation that leads to reproductive capacity and further psychosocial development (5:10). For autistic individuals, who often experience challenges with social communication, adaptability to change, and sensory sensitivities, navigating these developmental milestones can be particularly complex.
The presenter explains that early onset puberty can increase the risk for mental health problems, such as anxiety, depression, and suicidality, which are already more prevalent in adolescents with autism (05:58). Until recently, research on puberty and autism has been limited. Some recent studies suggest that while social cognition might improve during puberty, social withdrawal can intensify, and about a third of youth experience significant psychosocial problems. Further, female-presenting autistic people have reported challenges with emotion regulation and heightened sensory experiences during menstruation (08:06).
- A Two-Hit Model of Autism: Adolescence as the Second Hit (Picci & Scherf, 2015)
- Changes in Maladaptive Behaviors From Midchildhood to Young Adulthood in Autism Spectrum Disorder (Anderson et al., 2011)
- Autism after Adolescence: Population-based 13- to 22-year Follow-up Study of 120 Individuals with Autism Diagnosed in Childhood (Billstedt et al., 2005)
- Autism spectrum disorders and menstruation (Hamilton et al., 2011)
- In Search of Explanations for Early Pubertal Timing Effects on Developmental Psychopathology (Ge & Natsuaki, 2009)
- Pubertal Timing, Depression, and Externalizing Problems: A Framework, Review, and Examination of Gender Differences (Negriff & Susman, 2011)
- Other-Sex Relationship Stress and Sex Differences in the Contribution of Puberty to Depression (Llewellyn et al., 2012)
- Depressive and Anxiety Symptom Trajectories From School Age Through Young Adulthood in Samples With Autism Spectrum Disorder and Developmental Delay (Gotham et al., 2015)
Puberty onset and measurements
Corbett briefly describes methods for measuring puberty, including Tanner staging (physical exam), parent report (e.g., Pubertal Development Scale), and self-report (e.g., gender-specific self-assessment questionnaire) (09:27). She outlines a recent publication by her team which found that pubertal assessments by parent or child are not reliable indices of precise pubertal staging, compared to physical exams (11:05). Corbett and her team use all three methods of measurement in their studies to compare perceived development with physical indices. The speaker touches on models and frameworks used to help understand the links between mental health, puberty, and autism.
A study published by Corbett and colleagues in 2020 shows that autistic females experience significantly earlier breast development and onset of menses compared to typically developing females, while pubertal onset for autistic males is similar to neurotypical males (13:15). A longitudinal study assessing the progression of puberty in the same participants between 10 and 15 years of age verified these findings. Corbett reiterates that pubertal onset “sets into motion a cascade of events which may magnify and further complicate an already vulnerable trajectory, especially in females (17:00).”
- Pubertal Development Measurement in Children With and Without Autism Spectrum Disorder: A Comparison Between Physical Exam, Parent- and Self-Report (Corbett et al., 2019)
- Pubertal Timing During Early Adolescence: Advanced Pubertal Onset in Females with Autism Spectrum Disorder (Corbett et al., 2020)
- Examination of pubertal timing and tempo in females and males with autism spectrum disorder compared to typically developing youth (Corbett et al., 2022)
Altered cortisol levels in autism
The speaker describes the Hypothalamic-Pituitary-Adrenal (HPA) axis, which plays a vital role in our stress response by triggering a neuroendocrine cascade to produce cortisol. Cortisol, she continues, is a widely used biological marker found in blood and saliva (19:00). Normally, cortisol levels peak in the morning and decline throughout the day. However, Corbett’s research consistently shows that autistic children exhibit significant variability in cortisol levels, with persistently elevated evening cortisol and a “blunted slope” compared to their allistic peers. This means their cortisol doesn’t rise or drop to the same level, impacting their ability to feel energized during the day and rest well during the night (20:30). Another longitudinal study on cortisol trajectory further revealed that HPA axis maturation is impacted by age, puberty, sex, and an autism diagnosis, where females had higher overall cortisol and higher evening cortisol than the males in both groups (22:00).
- The developmental trajectory of diurnal cortisol in autistic and neurotypical youth (Corbett et al., 2023)
Psychological well-being: depression in autistic adolescence
The presenter notes that half of all people who will suffer from mental illnesses have their onset by age 14, making adolescence a critical period for mental health, especially for autistic youth. A study conducted by Corbett and Dr. Jessica Schwarzman found that depressive symptoms are significantly higher in both autistic males and females as early as 10-13 years of age. Parents corroborated these findings, reporting higher depressive symptoms in their autistic children, especially in females (25:25). The presenter therefore asserts that screening and intervention for depressive symptoms for autistic individuals should begin very early in adolescence. She notes that symptoms were often related to interpersonal problems and feelings of worthlessness, which are crucial intervention targets (28:00).
Corbett outlines a recent longitudinal study on the trajectory of depressive symptoms which revealed that while autistic individuals reported significantly higher depression symptoms at age 10, their symptoms actually decrease through adolescence, contrasting with an increase seen in allistic youth around ages 14-15 (30:00). The speaker notes that if replicated, this data warrants significant attention, potentially pointing to earlier identification and treatment for autistic youth.
- Higher depressive symptoms in early adolescents with Autism Spectrum Disorder by self- and parent-report compared to typically-developing peers (Schwartzman & Corbett, 2020)
- Diagnostic- and sex-based differences in depression symptoms in autistic and neurotypical early adolescents (Schwartzman et al., 2022)
- Trajectory of depressive symptoms over adolescence in autistic and neurotypical youth (Corbett et al., 2024)
Hormonal differences
Corbett explains that imbalances in hormones such as testosterone may modulate autism phenotypes. However, there is limited research regarding variations in testosterone during adolescence in autism (34:15). She details a recent study comparing salivary testosterone between autistic and allistic groups and male vs. female participants, with considerations of developmental stage. Data show that in autistic youth, both males and females exhibited significantly elevated testosterone compared to allistic youth. While male testosterone levels rapidly increased as expected during adolescence, females initially had higher testosterone until around 11.5 years of age before plateauing. Corbett states that these findings may suggest testosterone does play a role in autism, especially during periods of hormonal change (36:00).
- Salivary testosterone in male and female youth with and without autism spectrum disorder: considerations of development, sex, and diagnosis (Muscatello et al., 2022)
Gender diversity in autistic young people
Adolescence is a time of profound self-exploration, including gender identity, or a person’s innate sense of gender. The speaker highlights recent research suggesting a higher prevalence of gender diversity in individuals diagnosed with autism or having autistic traits compared to their allistic peers. Corbett’s team used both self-report and parent report questionnaires to confirm this finding in autistic children (37:00). Parents of autistic children reported significantly greater “gender body incongruence” in their children compared to parents of allistic children. Furthermore, within the autistic group, those assigned female at birth reported significantly more experiences of gender body incongruence than those assigned male. Self-reports from autistic youth also indicated significantly more reports of both “gender diversity” and “non-binary diversity” (40:00).
A follow-up study assessing gender diversity throughout adolescence found that gender incongruence was relatively stable across puberty in males (autistic and allistic). In contrast, autistic females endorsed greater incongruence around age 10, followed by a short plateau and then another increase. Allistic females reported the opposite pattern. Corbett summarizes these findings, highlighting the sex-based differences that indicate greater gender diversity in autistic females assigned at birth (AFAB). She also reiterates that gender identity formation is nuanced and likely influenced by pubertal progression, hormone patterns, and psychosocial factors (42:00).
- Greater Gender Diversity among Autistic Children by Self Report and Parent Report (Corbett et al., 2023)
- Gender diversity in autistic and neurotypical youth over adolescence and puberty: A longitudinal study (Corbett et al., 2024)
Conclusions & future research
Corbett summarizes the presentation, highlighting that autistic females enter puberty earlier than autistic males and allistic groups. Autistic young people also have a higher rate and earlier onset of depression and a greater prevalence of gender diversity, especially in females. The speaker underscores the need for comprehensive measurements of psychological variables based on self-report, parent-report, and clinical-report. She emphasizes the need to identify risks and opportunities for resilience to elucidate and support the dynamic transition of puberty (43:00).
Corbett and her team recently received funding to renew their longitudinal study of pubertal development. The renewed study aims to examine pubertal development through age 17 by observing physical development, hormones, menstruation, social communication, and internalizing symptoms. It also aims to observe the nervous system during these periods in a group of more than 300 participants (45:00). She notes an ongoing female development study before the Q&A (47:30).
Blythe A. Corbett, Ph.D., is the James G. Blakemore Chair and Professor in the Department of Psychiatry and Behavioral Sciences at Vanderbilt University Medical Center. She is the Director of the Social Emotional NeuroScience Endocrinology (SENSE) lab, a translational research program focused on better understanding and treating social competence and stress in children, adolescents and adults with autism spectrum disorder (ASD) across development.
In recent years, Dr. Corbett’s research has led to important findings related to the timing and trajectory of puberty, adolescence and mental health. Through generous support from the National Institutes of Health (NIMH) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Dr. Corbett’s research aims to better understand, support and track development, especially in autistic females. To date, Dr. Corbett’s program of research has led to over 95 original peer-reviewed articles in leading academic journals.
0:00– Introductions & outline
5:10 – Adolescence, puberty & associated risks
9:25 – Measuring puberty
13:15 – Autistic vs. allistic pubertal onset
19:00 – Cortisol levels in autistic young people
25:25 – Depression in young people with autism
32:15 – Testosterone and development
37:00 – Gender identity
43:00 – Conclusions & future research
47:30 – Q&A
Cited Studies
The current study prospectively examined trajectories of change in symptoms of irritability, hyperactivity, and social withdrawal, as well as predictors of such behaviors, for ages 9–18 years for youths with autism spectrum disorder and a comparison group with nonspectrum developmental delays. Children with more severe core features of autism had consistently higher irritability and hyperactivity scores over time than those with broader autism spectrum disorder and nonspectrum delays. Across all diagnoses, behaviors related to hyperactivity showed the greatest improvement. Social withdrawal worsened with age for a substantial proportion of youths with autism spectrum disorder but not for the nonspectrum comparison group. Compared with youths without autism spectrum disorder, children with the disorder showed greater heterogeneity in trajectories for maladaptive behaviors.
Background: Prospective population-based follow-up study of 120 individuals with autism followed from childhood to adulthood. Methods: Individuals with autism, diagnosed in childhood, were followed prospectively for a period of 13–22 years and re-evaluated at ages 17–40 years. The instruments used at follow-up were the DISCO, WAIS-R, WISC-III, Vineland Adaptive Behavior Scales, psychiatric-medical examination and GAF-scale. A set of criteria was used for the classification of outcomes, taking into consideration employment, higher education/vocational training, independent living and peer relations. Results: Six of the 120 (5%) had died at the time of follow-up, and six declined participation. Overall outcome was poor in 78% of cases. Only four individuals were independent albeit leading fairly isolated lives. Childhood IQ-level was positively correlated with better adult outcome, as was the existence of some communicative phrase speech at age six years. Conclusions: Children with autism as diagnosed in the 1960s, 1970s, and 1980s may have an even worse psychosocial outcome than previously believed.
We assessed the experience of 10-25-year old women with autism spectrum disorders with menstruation through their caregivers by investigating hygiene concerns, dysmenorrhea, premenstrual syndrome, and treatments. Frequent and severe symptoms of dysmenorrhea and premenstrual syndrome were common but had moderate morbidity rates. Hormonal contraception and other treatments were underused.
The purpose of this report is to synthesize the existing literature on pubertal timing and (a) depression and (b) externalizing behavior within a theoretical framework of risks, transitions, and psychological development during adolescence. This review first proposes a framework for considering pubertal timing and maladaptive behavior. Next, the literature on pubertal timing and depression is discussed, followed by the literature on pubertal timing and externalizing behavior with fine distinctions being made for males and females. Additionally, mediating and moderating variables are reviewed in an effort to understand mechanisms by which timing of puberty and maladjustment may operate or risk factors that may amplify the detrimental consequences of the pubertal transition. Finally, conclusions and future directions are proposed.
Adolescence is a time of remarkable biopsychosocial change, which may be particularly challenging for youth with autism spectrum disorder (ASD), necessitating enhanced understanding and accurate assessment of pubertal maturation. The study compared physical examination to parent- and self-report measures in 200 participants (134 males and 66 females) ages 10.0–13.5 years. Both participants with typical development (TD, n = 78) and ASD (n = 122) were included. Concordance ranged from slight-to-fair for self-assessments (κ = .17–.32) and slight-to-moderate for parent-report (κ = .21–.44). Concordance of physical exam with self- and parent-report of the ASD group was somewhat lower than for the TD group. Findings indicate pubertal assessments by parent or child are not reliable indices of precise pubertal staging.
Autism spectrum disorder (ASD) is characterized by impaired social communication and poor adaptation to change; thus, pubertal development may be precarious. Pubertal timing and tempo were measured in 244 youth (7.9% Black, 83.3% White, and 8.7% multiracial) with ASD (N = 140) and typical development (N = 104). Pubertal development was measured using Tanner staging of Genital (G, males), Breast (B, females), and pubic hair (PH) in both sexes at Year 1 (10-13 years), Year 2 (11-14 years), and Year 3 (12-15 years). Nonlinear mixed effects models analyzed interindividual differences in timing and tempo. For both sexes, ASD and higher body mass index were associated with earlier pubertal timing. Males generally exhibited faster tempo than females. Linear regression models did not show associations between pubertal timing and internalizing symptoms at time three. Findings showing advanced pubertal maturation in ASD youth suggest greater risk of psychological, social, and physiological challenges. LAY SUMMARY: Youth with ASD have difficulty in social communication and adaption to change, thus puberty may be a challenging transition. The study examined onset (timing) and progression (tempo) of puberty over three years, using physical exam, in 244 adolescents with and without ASD, enrolled at ages 10-13. ASD youth started puberty earlier, while males generally progressed at a faster pace. Further examination of puberty in ASD should identify impact on social, behavioral, and mental health outcomes.
Increasing age and puberty affect the hypothalamic pituitary adrenal (HPA) axis maturation, which is likely associated with an increase in environmental demands (e.g., social) and vulnerability for the onset of psychiatric conditions (e.g., depression). There is limited research as to whether such patterns are consonant in youth with autism spectrum disorder (ASD), a condition marked by social challenges, dysregulation of the HPA axis, and higher rates of depression setting the stage for enhanced vulnerability during this developmental period.The current study interrogated diurnal cortisol by examining (1) cortisol expression longitudinally over the pubertal transition between autistic and neurotypical youth, (2) the trajectory of diurnal cortisol and the unique contributions of age vs. puberty, and (3) potential sex differences. As hypothesized, results indicate autistic compared to typically developing youth demonstrate a shallower diurnal slope and elevated evening cortisol. These differences were in the context of higher cortisol and flatter rhythms based on age and pubertal development. Also, sex-based differences emerged such that females in both groups had higher cortisol, flatter slopes, and higher evening cortisol than males. The results show that despite the trait-like stability of diurnal cortisol, HPA maturation is impacted by age, puberty, sex, as well as an ASD diagnosis.
Depression is more prevalent among male early adolescents with Autism Spectrum Disorder (ASD) than their typically- developing (TD) peers, but findings are limited to two male-only studies. Therefore, a broader understanding of depressive symptoms among both male and female early adolescents with ASD in larger samples is needed. Self- and parent-ratings are frequently used, yet rater differences may emerge and provide unique insights.
Depression is more common in autistic adolescents than their neurotypical peers, but the effects of diagnosis and sex on the severity and types of depressive symptoms remain unclear. The study explored diagnostic- and sex-based differences in depressive symptoms in 212 autistic and neurotypical early adolescents. Results show that autism spectrum disorder and female may pose elevated risks, and depressive symptoms related to interpersonal problems and negative self-esteem are more frequent in autism spectrum disorder. Autistic males and females endorsed similar severity and type of depressive symptoms, but unique differences emerged when compared to sex-matched neurotypical peers. Exploratory analyses in a clinical subsample of early adolescents with elevated depressive symptoms (Children’s Depression Inventory, Second Edition, Total T-score ⩾60) revealed more endorsement of beliefs of worthlessness in autistic early adolescents. Findings suggest initial intervention targets for treating depression in autistic early adolescents.
Adolescence coincides with a dramatic rise in the onset of psychiatric conditions including depression. Depression symptoms may be particularly prevalent and impairing for youth with autism spectrum disorder (ASD). While prior research suggests adolescence is associated with worsening depression symptoms for typically developing (TD) and autistic youth, it is unclear if they follow a similar course.
Puberty is characterized by significant physical, hormonal, and psychological changes, which may be especially challenging for individuals with autism spectrum disorder (ASD). Although the etiology of ASD remains uncertain, studies suggest imbalances in hormones, such as testosterone, may modulate the autism phenotype. While differences in fetal and postnatal testosterone have been reported, there is limited literature regarding testosterone variations during adolescence in ASD. We investigated morning salivary testosterone levels in youth with ASD and typical development (TD) to explore hypothesized differences, expecting elevated hormonal levels in ASD compared to TD.
Emerging research suggests over-representation of gender diversity among autistic youth. Previous gender diversity research with autistic children has relied on parent-report based on a single question. The Gender Diversity Screening Questionnaire self-report (GDSQ-S) and parent-report (GDSQ-P) assessed gender diversity experiences from 244 children (140 autism spectrum disorder (ASD) and 104 typically developing (TD)) between 10-to-13 years, and their parents. Parent-report Child Behavior Checklist Item-110, “Wishes to be the opposite sex” was also collected. Autistic children endorsed higher GDSQ-S Binary Gender Diversity, t(223.21)=−2.83, adjusted p=0.02, d=−0.35, and Nonbinary Gender Diversity, t(191.15)= −3.79, adjusted p= 0.001, d=−0.46, than TD children. Similarly, for GDSQ-P, there was a significant Gender Body Incongruence difference between the groups, t(189.59)= −2.28, adjusted p=0.05, d=−0.30. Within-group analyses revealed that parents of autistic females-assigned-at-birth reported significantly more gender Body Incongruence than males-assigned-at-birth, t(32.91)= −3.78, p<0.001, d=−1.11. Moreover, distinct within-group profiles of gender experiences and internalizing symptoms were revealed, showing associations between gender profiles and symptoms of anxiety, depression, and suicidality. Results extend reports showing increased rates of gender diversity in autistic children based on both self- and parent-report, underscoring the need to better understand and support the unique and complex needs of autistic children who experience gender diversity.
Recent research in autism spectrum disorder (ASD) has suggested a higher prevalence of gender diversity in individuals diagnosed with ASD. Adolescence is a critical period for the consolidation of gender identity, yet the extent to which the experience of gender diversity is stable over adolescence and puberty in autistic youth is poorly understood. The aim of the study was to examine the consistency of gender diversity using the gender diversity screening questionnaire for self- and parent-report of youth (GDSQ-S, GDSQ-P) over a four-year longitudinal study of pubertal development in youth with ASD (N = 140, 36 assigned-female-at birth (AFAB)) and typical development (TD, N = 104, 58 assigned-male-at-birth [AMAB]) and their parents. The extent to which diagnosis (ASD vs. TD), assigned sex (AFAB vs. AMAB) and developmental level (age, puberty) predict GDSQ trajectory over time was explored. There was a significant diagnosis by sex-assigned-at-birth by age interaction for GDSQ-S Gender Diversity, p = 0.002, showing higher scores in autistic AFAB youth over adolescence, and TD AFAB showing initially lower, then increasing levels over adolescence. For GDSQ-P, Gender Incongruence was significantly different between the groups, p = 0.032, showing higher incongruence for autistic AFAB around age 10, decreasing between age 12-14 before increasing again, while TD AFAB evidence the inverse trend. AMAB trends were stable. The significant diagnostic, developmental and sex-based differences indicate AFAB youth experience greater gender diversity that evolves over development. Findings suggest gender identity formation is nuanced and may be influenced by pubertal progression, hormonal patterns, and psychosocial factors. Results underscore the need for enhanced understanding of the unique, dynamic profiles of females-assigned-at-birth.
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