Autism and Puberty

Puberty involves big changes and new challenges for any child. But for kids with autism spectrum disorder (ASD), it can be especially difficult to navigate.

Changes in the body can be disturbing to autistic teenagers, who tend to have a hard time handling change in general. Navigating more complex social norms can be confusing, making kids feel isolated and putting them at risk for depression. And turbulent emotions can lead to challenging or harmful behaviors.

“Providing information and support is crucial to help these kids get through puberty without it being really overwhelming and scary,” notes Margaret Dyson, PhD, a psychologist in the Autism Center at the Child Mind Institute. “And we don’t want them to be vulnerable to being taken advantage of by others.”

Dr. Dyson’s first advice to parents and other caregivers is to start a conversation with their child about puberty well before it happens. “It’s easier if you can do it proactively,” she says. Making a plan ahead of time will allow you to think through what information you’re going to share, and give you plenty of time for the repetition kids on the spectrum may need to get comfortable with it.

Children usually enter puberty between the ages of 8 and 14 — but for some, it may begin earlier. Dr. Dyson notes that girls often begin menstruating 12 to 18 months after they start developing breasts.

Children on the autism spectrum may need extra support to reduce anxiety around changes in their bodies and the new physical sensations that come with them, Dr. Dyson says.

For instance, girls should know what happens when you get your period and how to manage menstrual bleeding before it happens. But they may also need help understanding that cramps and other body aches are a normal part of the experience, too.

That said, extreme menstrual pain and/or bleeding could indicate a condition that requires treatment. Dr. Dyson suggests using pain charts to help girls indicate what’s going on in their body — i.e., on a scale of 1 to 10 — if they’re not able to verbalize what they’re feeling.

Dr. Dyson recommends showing girls how to use a pad, tampon, or menstrual cup and encouraging them to pick out their own supplies at the store. Making a visual schedule of how often a product needs to be changed can help them anticipate how often they will need to pay attention to menstrual care, and how they might fit it into their routine.

For boys, Dr. Dyson advises explaining what getting an erection and ejaculation are before the first time they’re likely to happen, as well as clarifying that nocturnal emissions or “wet dreams” are not urinating in bed. Not understanding these functions can make them feel out of control of their bodies.

Some kids who have both autism and epilepsy experience an uptick in seizure activity at puberty.

During adolescence, kids will begin to experience sexual urges and need to understand what they are feeling. Regardless of whether or not the teen is likely to become sexually active, experts say they should be informed about sex and reproduction. And by talking to them about it proactively, you have the chance to discuss your family’s values and cultivate a safe space for your child to ask questions.

Dr. Dyson suggests beginning conversations about sexuality by asking the child what they already know and building on it. She also advises using correct language for body parts and functions, rather than euphemisms. Answering questions simply, directly, and in a positive tone will help encourage your child to continue to come to you when they have questions.

Explaining the process of sexual maturity can be done with the aid of visual resources and social stories, she adds, emphasizing that this is a natural part of becoming an adult.

Anticipating that kids will be experiencing sexual urges leads to the need for a conversation about the difference between what Dr. Dyson calls public and private behaviors.

For instance, experts recommend teaching kids that masturbation is a natural behavior — there’s nothing wrong with it — but that it should be done in private. “You don’t want to be shaming the young person,” notes Dr. Dyson, “but just making that distinction clear for them.”

Visual resources can be helpful to make these concepts more concrete. For example, the Vanderbilt Kennedy Center offers a Healthy Bodies Toolkit that includes visuals. One of them uses concentric circles to designate different kinds of relationships, from strangers on the outside ring to romantic partners at the center. Each ring indicates the kinds of behaviors that are appropriate for that relationship — for example, it’s okay to smile and say hello to strangers, but kissing should be reserved for romantic partners.

Feeling attracted to someone can be confusing to kids on the spectrum, as is knowing when to share or act on their feelings. Dr. Dyson suggests emphasizing that feeling attracted to someone is normal and healthy. But it’s important to clarify that sexual or romantic attraction is something we want to keep private except in appropriate situations, and when we have reason to think the other person welcomes the attention. Kids also need to learn what is appropriate or inappropriate touch, and the basics of consent — as she puts it, “recognizing private areas of other people’s bodies as well as your own, and the need to ask for permission prior to moving into that more private zone with someone.”

Vanderbilt suggests covering some of these topics:

• Why do people have sex?
• How do you know when you are ready for sex?
• What are sexual feelings?
• Where are appropriate places to have sex?
• What are the different ways to have sex?
• What is pornography?
• What is consent?
• How do you identify consent?

Gender and sexual preferences are related issues that autistic kids will need to navigate, for themselves and in interacting with their peers. Of course, teens who might be sexually active need to understand how to protect against pregnancy and sexually transmitted diseases.

For kids on the spectrum, understanding the nuances of interacting in the more sexualized context of adolescence can be very challenging, as it often includes indirect signaling and body language. “We talk to kids about what are those signs that someone may be interested in you,” Dr. Dyson notes, “and then what are those signs that maybe they’re not as interested, or they’re not feeling comfortable in an interaction.”

Some, especially girls, find it difficult to understand why their more sexually mature friends are showing increased interest in their peers, or engaging with them in a different way, like flirtation or hugs or kissing. “That can sometimes be challenging for a more neurodivergent individual to understand,” notes Dr. Dyson.

During adolescence, kids become increasingly focused on their friends. Those on the spectrum may need extra support figuring out who to make friends with and how to go about it. Talking to kids about what makes a good friend can help them avoid being taken advantage of by kids who don’t have their best interests at heart, Dr. Dyson says.

“It’s important to have a conversation with your teen about what are those qualities that we’re looking for in a good friend,” she explains. “For instance, you want them to be trustworthy and caring. You likely want to have some shared interests with them. You obviously want to have a reciprocal relationship, so it’s not just you doing all the work.”

Around puberty, autistic kids tend to become more aware of their social challenges and have a harder time fitting in. Some may find themselves the target of bullying. This increasing awareness of being different, and feeling isolated, can be very painful, making kids on the spectrum more prone to anxiety, depression, and disordered eating. For some, their confusion and discomfort might present in challenging behaviors.

An increase in self-injury, changes in appetite or sleep patterns, frequent complaints of headaches and stomach aches, or an abrupt loss of interest in activities they used to enjoy can all be signs of depression that warrant professional support.

For some kids on the spectrum, hormonal changes and emotional turbulence can bring about more challenging or aggressive behavior. And with kids growing to be as big or even bigger than their parents, Dr. Dyson suggests planning ahead for how to handle it. This could entail identifying triggers for potentially dangerous behaviors and strategies for preventing them. For some kids, medications like Abilify or Risperdal are prescribed around the age of puberty to help manage behaviors that could be harmful to themselves or others.

Dr. Dyson suggests making sure you’re working with a therapist or another mental health provider to get support and have a good safety plan in place for your child, including those who are prone to wandering, or elopement, or who might have outbursts in public.

Since interest in social media often intensifies in adolescence, another concern for keeping autistic teenagers safe is monitoring appropriate behavior online. Experts stress having clear rules that kids can learn and be able to access quickly when making social media decisions.

Some of those rules, the Vanderbilt toolkit suggests, might include:

• Do not share your address or certain personal information on the internet.
• If you post pictures, make sure they are pictures that you would be okay with anyone seeing, including children and your family.
• Remember that even a conversation that seems private via messaging can be copied and shared with others.

But kids on the autism spectrum may need more support to avoid being taken advantage of online or targeted by cyberbullies. Dr. Dyson notes that they may be less quick to recognize that people are not always who they seem online, and that people who appear friendly may not have their best interests at heart.

Experts urge thinking carefully about when kids are ready to handle social media. Common Sense Media offers a host of resources to help parents understand various social media platforms and help keep kids’ exposure to them as healthy as possible. Kids on the autism spectrum are not alone in being at risk, but social challenges may make them particularly vulnerable to bad actors — or just insensitive peers — online.