If "X Changes the Brain!!!", When Should We Care?

In a post catchily titled "Warning: This Post Will Change Your Brain," Neuroskeptic describes media coverage that breathlessly reports that a single dose of an antidepressant changes the brain.

As Neuroskeptic points out, evidence from brain damage supports the idea that everything the mind does involves corresponding brain activity.  Therefore, we should expect, at some level, that everything we think about, do, or perceive will change the brain in some way.  There are a lot of philosophical positions you could take that are compatible with this notion--that "the mind is what the brain does," that "the mind is the brain," that "the brain causes the mind to do stuff," that "the mind and the brain just happen to perfectly parallel each other," and so on. Regardless, if something is happening in the mind, then something must be happening in the brain, too. Therefore, the mere existence of a change in the brain isn't necessarily headline news. Neuroskeptic has a great example of trivial brain changes we experience every day:

"Every time you open your eyes, for example, widespread changes in your brain activity result. But every time you close your eyes, these changes are reversed."
Above: "Sleep changes the brain?!  I'd better not sleep any more, then!"

Given all the headlines with titles like "New brain study explains why people do/like/think X," journalists do seem to believe that the brain either is or causes what happens in the mind.  So if they really believe this, they should also recognize that mind changes necessarily involve brain changes, so not every brain change is likely to be exciting or important.

So if some brain changes are trivial, how are we supposed to evaluate whether a change reported in a news story should matter to us?

It may not always be possible to tell, given either the limitations of the study or the article reporting on it.  But here are some questions one can ask:

1) At what time scale does the brain change?
Brain plasticity acts at two major time scales.  One, on the order of milliseconds, involves changes in the pattern of neural firing, and the biochemical processes that affect it--neurotransmitter release and the like.  Different neurons in your visual cortex fire when you look at a perfectly vertical line versus when you look at a perfectly horizontal line, for example.  Different assemblies of neurons will fire when you look at (or think about) a cat and when you look at (or think about) a dog; or when you smell Lysol vs. your grandmother's cookies.  And each time you think about something new, the pattern of neurons that fires changes again.  These changes are so fast that fMRI is too slow to catch them.  On the other hand, over years, memories form and solidify through changes in the strength and structure of synapses.

2) How long does the change last?
Brain plasticity at the millisecond scale lasts as long as the thought or behavior it signifies. Long term potentiation--the brain changes that enable memory formation--can potentially last as long as an individual lives.

3) What sort of change is it?  How big is it?
The birth of new neurons and the creation of new synapses is a big deal. For example, a major factor in developmental changes is a proliferation of synapses in a particular brain region, followed by a pruning of the synapses that turn out not to be useful.  Some regions, such as primary visual cortex at the very back of the brain, both proliferate and prune earlier than others, such as the frontal lobe, and this has real behavioral consequences.  Long-term changes in the pattern of short-range and long-range white matter connections in the brain also seem important, as do changes in the functional communication between brain regions that they enable. Look for evidence of large, long-lasting, long-time-scale changes of this sort.    

4) How and why does the change happen?
This is really a question about the mechanisms of the brain change, which, for a neuroscientist, means understanding its effects at all levels, from the molecular up to the whole brain level.  But a layperson can approach the question in a less technical way.  Suppose the brain change is caused by a drug or therapy.  Do these changes simply reflect the transient action of the drug or therapy, and end once the patient is no longer in treatment?  Or does the drug or therapy change the brain in some sort of meaningful way that persists even when the patient is no longer receiving treatment?  For example, people helped by cognitive-behavioral therapy for anxiety may develop habits of examining and correcting their thinking that become so effective that they no longer needs the therapy, because they have been trained to provide their own.  One might expect to see a long-lasting, long-time scale brain change of one of the sorts described in Question 3.

5) What is the real-world, behavioral consequence of this brain change?  Is there one at all?
As Dorothy Bishop points out, teachers don't really care if a dyslexia intervention changes the structure or function of the brain in some way; they care if it teaches dyslexic children to read faster and more accurately, and if this improvement lasts.  A depressed person evaluating possible therapies wants to know if changes in the brain reflect an actual reduction in depression symptoms.  In cases like this, brain changes are interesting because they may inform us about how the behavioral change occurs, but the real measure of interest is behavioral, not neurological.
Next time you read a headline about how something changes the brain, keep these questions in mind and ask yourself what sort of brain changes are actually involved.  The reality may be less exciting, or terrifying, than it first appears.


An Open Letter to Issy Stapleton

Dear Issy,
I don't know if you have free access to the internet, or if you'll ever see this.  But I wanted to tell you something.

I can't even imagine what it's like to live knowing that your mom tried to kill you.  That would traumatize anybody.  Worse, to have to listen to her tell the world that it was your fault, that you didn't deserve to live, and having famous people like Dr. Phil agreeing with her.  Well, I know it hurts, and it's probably infuriating, but I want you to know, it's not your fault.  You don't deserve this. No one does.

Please know that there are a lot of people who support you, who want the best for you, who wish we could protect you.  A lot of people are trying to make the world see that what your mom did to you was wrong.  We couldn't help you, but maybe we can stop it from happening to another child.

And Issy, you're not alone.  There is a whole community of people affected by autism who are very different from your mother.  There are autistic adults* who talk to each other online and meet in person.  An incredibly diverse group of people, many of whom were called "difficult" and treated horribly when they were children, but who now are friends and support each other.  There are parents of autistic kids who treat them kindly and want to understand them, who don't see their children as a burden.  There are siblings, like myself, who know their lives are infinitely better because of their autistic sibling.  There are professionals who actually care about the happiness of the people they work with, not just about making them look "normal."  We're all here waiting to welcome you.

With love,
Emily "Mosaicofminds"

*I don't know if you prefer "autistic" or "with autism" or if you care one way or the other.  This is the term I use, but please fill in whatever you prefer.


Want to learn how something works in psychology? Make it up!

(No, I don't mean that you should invent numbers and call them experimental data, although some people have done that).

There are a lot of theories psychologists have been unable to prove, either because they lack the control over the world necessary to test them, or because it would be unethical to do so.  For example, the nature/nurture problem would be a lot easier to solve if one could separate twins at birth and assign them, say, to a "learn a spoken language" and a "learn a sign language" condition, or an "authoritarian parent" and a "laissez faire parent" condition.  But, since they can't do such things, psychologists have come up with a creative alternative.

They create artificial versions of the things they want to study.

Want to know how people learn a language?  Make up an artificial language, change the parameters of its grammar and other qualities in specific ways, and watch how people learn it.  There are a number of studies that have used invented artificial languages to study language learning in kids and adults.  On a smaller scale, studies routinely examine toddlers' word learning by asking them to learn the names of toys or unfamiliar household objects--names like "blicket" or "dax."

Want to understand how we learn to recognize specific types of objects, such as faces?  One research group invented little creatures called Greebles. They trained people to recognize individual Greebles and categorize them into families.  They varied what methods were used to train people to recognize the Greebles, how participants were tested, and various other parameters in order to find out more about the learning processes involved.  They also observed (using fMRI) how learning to recognize these artificial objects changed activation in a specific area of the brain important for object recognition.

Above: Greebles, from Isabel Gauthier's paper in Nature Neuroscience.

My own lab even used 3D printers to create Greeble-like creatures for children to play with while learning (Sorry, no pictures available at present).  Doing so allows them test whether the experience of touching and looking at the Greebles from different angles helps children learn them.  They also investigate whether it matters exactly how children explore the objects.  There are families of Greebles living on my desk and they are adorable. (And these are just the most appealing of a wide variety of artificial objects my lab has used to study how young children learn).

Other than writers and video game designers, how many people in other fields can say they made up a language or a new type of creature?  How many can say they did it for science?


How do developmental psychologists think?

[The basic structure and ideas for this post come from a developmental seminar I'm taking with Dr. Bennett Bertenthal at Indiana University.  I'm sharing these concepts more broadly because not everyone has access to a class like this, but anyone interested in child development can benefit from understanding the thinking style and assumptions of the people who research it.] 

A developmental psychologist is someone who researches how people's minds change over their lifetime.  Most study babies, children, or adolescents, but some focus on old age, and they could also investigate parenthood, middle age, or emerging adulthood.  Developmental psychologists care about life stages, how we change as we transition from one to the next, how we change within a life stage, and conversely, what about us stays the same as we move from one stage to another.

Above: A developmental psychologist playing with a child.

Developmental psychologists are concerned with processes of continuity and change rather than in particular things the human mind does.  In this respect, they are different from some other sorts of psychologists, who are defined by the functions of the human mind they choose to research.  (I.e., cognitive psychologists study thought and perception, personality psychologists study personality, and social psychologists study group behavior and influences).  Developmental psychology, as a field, is concerned with all these areas of the human mind. Even a developmental psychologist who focuses on cognitive psychology topics--as I do--will have some familiarity with personality and social development.

First, I'm going to lay out some assumptions developmental psychologists make. Then I'll list some big questions they like to ask.

1) Gene Environment Interactions
While the nature-nurture debate is at least as intense among developmental psychologists as elsewhere, they have a unique perspective on it.  They argue that you cannot explain human behavior with only genes or only experiences.  Instead, they come together in a complex way, with different results than you would get from genes or environment alone.  They claim that the interaction between genes and environment resembles that between vinegar and baking soda.  Vinegar and baking soda are each inert, but come together to make an explosive reaction.  Similarly, genes and environment come together to create an outcome--like personality traits or intelligence--that neither would have produced alone.

The least controversial interaction is probably height.  A large amount of variation in people's heights is genetically determined; tall people tend to have tall children, short people tend to have short children, and siblings tend to have similar heights.  However, nutrition determines whether people will grow as tall as their genes permit them to be.  For this reason, my grandparents were taller than my great-grandparents, and my parents were taller than my grandparents (and the same will likely be true for you, as well). However, improvements in nutrition seem to have plateaued, and so has height; my generation (millenials) is the first in some time not to exceed their own parents' height. Notice that the genetic relationships here (parent to child) are constant across the generations from your great-grandparents to yourself, but differences in environment (nutrition) produce large differences in height.

More complicated and controversial are theories like the Orchid Hypothesis, which posits that different people are differentially reactive to their environments (whether these are good or bad). As far as I know, this theory is still new and not completely accepted, but it's based on research on stress and resilience that is widely accepted.  It's pretty well known that some children who have suffered abuse and neglect will have worse life outcomes than others, and that one factor affecting this is differences in specific genes.

2) Developmental Trajectory
You don't have to be a developmental psychologist to notice that different individuals develop at slightly different rates.  For example, some kids are early talkers and readers and remain ahead of their peers in language skills; other children are slower than their peers in developing language and reading skills. Some kids are taller than their peers from an early age, and maintain this status over time, while others start out short and remain that way.  More interesting than that, though, are children who start out behind their peers in a skill and come out ahead, or vice versa.  For example, Einstein, though a late talker, developed perfectly adequate speaking, reading, and writing skills by adulthood, and some late-talking children today follow a similar pattern.  Meanwhile, some children with precocious academic skills and high IQ scores in preschool, kindergarten, or first grade, may perform more like their peers by third grade (for this reason, experts on gifted children tend to recommend getting one's children IQ-tested at 6 or 7 years old). Children's rate of development of a skill can change, both relative to themselves at earlier ages, and relative to peers of the same age.  Basically, when developmental psychologists think about growth, they imagine a line graph, where the steepness of the slope of the line represents the speed of development, and changes in the slope represent changes in the rate of development over time.

Developmental trajectory is especially interesting in two cases: when comparing typical with atypical development, and when comparing outcomes for different individual children.

For example, language development often follows a different trajectory in autism than in typical development.  Speech is often delayed.  Also, the rate of growth may seem to slow down for a while, stop entirely (what developmental psychologists call a "plateau"), or even reverse ("regression" or loss of language).  On the other hand, language development may continue longer in autistic people than in neurotypical peers, with language skills sometimes improving into adulthood.  And of course, since autism embraces people with a wide range of characteristics, you will find autistic people with pretty much every imaginable trajectory of language development.  There have been lots of recent studies that attempt to find subgroups of autistic children with different trajectories, in the hopes of predicting who will have the best language outcomes, and why.

Developmental trajectory is also important when comparing different individuals from the same population.  For example, some late talkers eventually catch up with their peers in spoken vocabulary, while others do not.  Some developmental psychologists spend a lot of time trying to figure out why these children differ, and what can be done to help the persistently-delayed group catch up.

3) Developmental Cascades
While people can and do grow and change throughout their lives, earlier experiences profoundly shape our abilities and choices later on.  The influence of earlier upon later development is called a "developmental cascade."  A better term would probably be "developmental avalanche."

For example, let's say you're looking at vocabulary size from age 3 to age 5.

Age 3 vocabulary size has an effect on age 4 vocabulary size.
Age 4 vocabulary size has an effect on age 5 vocabulary size.
Age 3 vocabulary has an additional effect on age 5 vocabulary size.

So you have a sort of snowball where initial vocabulary has both direct influences and indirect ones, via vocabulary at intermediate ages. It's like a small snowball that hits more snow and becomes a bigger snowball, which hits more snow and becomes an even bigger snowball, and so on.  Eventually, small differences between people early on can lead to big differences later on.

4) 2-Way Interaction between child and environment
Children aren't just shaped by their environment. They can act in different ways, and their behavior in turn shapes the input they get from their environment.  For example, a child who is shy from infancy will be treated differently than a child who is outgoing from infancy.  They may be reproached, or gently encouraged to interact, or pushed hard to interact, or shamed into interacting, depending on their parents' parenting style and values.  This in turn will shape how the child behaves around other people, and whether they become painfully shy and retiring or quietly confident adults.  A child who has been told from an early age that they're smart will probably think of themselves differently, and take different levels of risk in the classroom, than a child who has been told that they're just average, or even dumb.  I'm sure you can think of many more everyday examples.

While the role of children in shaping their environment seems obvious when pointed out, it's very different from how your average parenting book describes children1.  Too often, the paradigm seems to be "push the right button, receive the desired behavior;" there is little focus on the children's reasons for their behavior (good or bad), or on how the children might be pushing the parents' buttons and triggering their own insecurities about parenting or other issues.  Not surprisingly, many of these books aren't written by developmental psychologists.

The four assumptions listed here lead cognitive psychologists to ask a certain set of questions.

Questions Developmental Psychologists Ask:
1) Are some capabilities innate? If so, which ones?
William James pointed out that at any given moment, there are so many shapes, colors, sounds, textures, smells, temperatures, and more that without any inborn means to sort them out, a baby's world would seem like a "blooming, buzzing confusion."  I think most developmental psychologists accept that at the very least, babies are born with some basic learning mechanisms and an inclination to observe and learn about the world.  But they differ on how much "software" babies come with.  Some people think we're born with (tacit) knowledge of all the grammatical rules of human language, a basic understanding of how objects move (e.g., that objects fall), and/or a set of basic concepts about other people (e.g., that they have minds and intentions).  Others think that we develop these concepts early in life, but aren't born with them.  This debate has led to a lot of interesting research on what babies understand about people, things, quantities, and more, and is far from being resolved.

2) Are there developmental stages, and if so, how do people transition between them?
Piaget thought there were certain qualitatively different ways of thinking that everyone progressed through in a certain order at roughly the same age, and that was consistent across domains of knowledge.  (I.e., if you are at the concrete operational stage in thinking about the movement of objects, then you must also be at the concrete operational stage in thinking about other people's behavior).  This is a fairly extreme stage theory.  His successors, the Neo-Piagetians, were a little more flexible, particularly regarding different domains of knowledge and individual differences.  However, they still thought that development has discrete steps, like a staircase, rather than continuity throughout, like a wheelchair ramp.  Whether a particular study seems to provide support for stage-like or continuous development seems to depend whether it uses continuous or discontinuous measures of the behavior in question, so this question is also far from being resolved.

3) How do individuals differ in their development?
I think this is fairly self-explanatory.

4) How do changes in the brain contribute to development?
This question is similarly easy to understand--but it's even harder to answer in kids than it is in adults.

5) What develops, and how does change occur?
Let's say that last year, Anna didn't understand conservation of matter, but this year she does, and can pass a Piagetian conservation of matter task.  How exactly is she thinking differently now than she did last year?  How did she get from the understanding she had last year to the one she has this year?  This is a very difficult and abstract question, is probably the most central question in developmental psychology, and is also probably the hardest to resolve.

6) How does the social world contribute to development?
We are constantly observing, imitating, and listening to explicit teaching from other people.  We grow up in cultures that provide us with tools for thinking like language, writing, the abacus, or the internet. Our cultures also determine how we spend our time at different ages, and whether we spend our time more with age peers or with people of all ages.  We interact with various institutions either directly or indirectly, including schools, churches, and governments.  We are assigned to categories of age, gender, ethnicity, religion, and more, all of which come with messages about how a person within our category "should" and "should not" behave.  We also (in general) have innate desires to learn from and connect emotionally with other people, and get them to like us.  All these things shape both what we experience and how we choose to behave.

So next time you talk to a developmental psychologist or read about a developmental study, know that development is all about change--and change is a complicated mass of factors that changes over time and differs between individuals. Their goal is to sort out that complex system.

1 I read parenting books from about 1995, when my brother was a fetus, to about 2008, when I got too busy with college to read them.  So it's quite possible I've missed books from before or after these dates that take a better approach. (And for that matter, I'm glossing over a few exceptional parenting books that appeared during this time, like The Heart of Parenting, which is based on the concept of emotional intelligence, and involves helping kids recognize and verbalize their emotions).


Eye movements in ADHD: Not a "foolproof" diagnostic method, but interesting and important

Above: Eye movements. Are they really a foolproof clue to ADHD?

Science Daily claims that measuring "Involuntary movement [is] a foolproof indication for ADHD diagnosis." Specifically, they believe it will reduce the rate of misdiagnosis in children:

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed -- and misdiagnosed -- behavioral disorder in American children. Now a new study can provide the objective tool medical professionals need to accurately diagnose ADHD. The study indicates that involuntary eye movements accurately reflect the presence of ADHD.

Unfortunately, the actual study, by Fried and colleagues1, indicates nothing of the sort.2

The study did, in fact, measure involuntary eye movements--specifically, blinking and "microsaccades," small jerky eye movements.

22 adults with ADHD took the TOVA twice, the first time unmedicated and the second time while taking methylphenidate (Ritalin).2  The TOVA, which stands for Test of Variables of Attention, is a common, computerized diagnostic test for ADHD.  While participants took the test, their involuntary eye movements were measured.  The unmedicated ADHD adults made more microsaccades and blinks than neurotypical adults immediately before the onset of the stimulus.  When they took the test a second time on methylphenidate, they did not differ from the control group. The researchers argued that measuring involuntary eye movements is more precise, quantitative, and harder to "game" than many current diagnostic methods, such as questionnaires and self-report.

Unfortunately, this study cannot possibly generalize enough to a wider population to imply anything about diagnosing ADHD in the real world.  First of all, although the Science Daily press release focused on children, and parents' concern about their taking stimulants unnecessarily, Fried's study only examined adults.  Furthermore, the study measured eye movements only during a single specific task, the TOVA.  It's not clear whether the same finding would occur during other tasks, or even at rest.  And of course, a sample of 22 participants may not generalize well to the millions of people with ADHD.

And even if the findings generalize to other ages and tasks, further conditions would need to be met to ensure the method worked in practice.  It would have to be tested in a real-world school or clinical setting, with a large population of people referred for possible ADHD (on the order of hundreds or even thousands).  It would have to successfully distinguish ADHD not only from typical development but from other forms of atypical development--which is much harder.  While most of the hysteria about ADHD misdiagnosis assumes that the misdiagnosed children are "normal" children treated as if they have a developmental disorder, it's probably more common for children to be misdiagnosed as having ADHD because of real symptoms caused by mental illness (such as depression), physical illness (such as sleep problems) or another developmental disability. Furthermore, the method would have to be shown to be cheap, fast, and practical in real-world contexts.  For example, the TOVA is a common diagnostic test among neuropsychologists and other specialists, but to the best of my knowledge, it is less so among pediatricians who may also be called on to diagnose ADHD. If the TOVA is essential to obtaining this pattern of eye movements, the method may not generalize well to all diagnostic settings.

This is not even the first study to identify increased anticipatory saccades as a marker of ADHD.  In a review, Rommelse and colleagues report five others (Castellanos et al., 2000; Mostofsky et al. 2001a & 2001b; Rommelse et al., 2008, & Ross et al., 1994; see reference list).  Bittencourt and colleagues' review described a study by Feifel and colleagues, who tested ADHD adults who went unmedicated at least 48 hours. These participants generated more anticipatory saccades when a task required them to shift their attention from central fixation to a target appearing randomly onscreen.

Furthermore, Richard N. Blazey, David L. Patton, and Peter A. Parks have a U.S. patent for a method of detecting ADHD through saccades, or what they call "angular movements of the eyeball."  Their patent differs from Fried's method in one crucial respect.  Eye movements are measured while the person sits staring at a blank screen, wearing noise-canceling headphones, rather than while doing a demanding test like the TOVA.

So Fried's study doesn't offer a foolproof way to diagnose ADHD, and measuring unconscious eye movements isn't a new way to diagnose ADHD in the first place.  But the paper still offers an important insight, one left unexplored by the Science Daily article.  ADHD adults make more anticipatory saccades than neurotypical adults, and it turns out that anticipatory saccades play an important role in perception and tell us something about the strengths and weaknesses of vision in ADHD.

In order to understand why the finding matters, let's briefly go over the research on what anticipatory saccades do and why they matter.

First of all, a saccade is a rapid, jerky eye movement that brings something new into focus on the fovea, the most sensitive part of the eye.  It is not the only sort of eye movement (there are also smooth pursuit eye movements that smoothly track a moving object already in focus).  However, it is extremely common and essential to vision.  As Michael F. Land explains:

“Throughout the animal kingdom, in animals with as diverse evolutionary backgrounds as men, fish, crabs, flies, and cuttlefish, one finds a consistent pattern of eye movements which can be referred to as a ‘saccade and fixate’ strategy. Saccades are the fast movements that redirect the eye to a new part of the surroundings and fixations are the intervals between saccades in which gaze is held almost stationary. As Dodge showed in 1900, it is during fixations that information is taken in: during saccades we are effectively blind.” 
Saccades can take in varying amounts of the visual field (measured in degrees).  Microsaccades, like the ones in the Fried ADHD study, are generally defined as extending to less than 15 minutes of arc in the visual field.

Even a cursory Google search reveals that anticipatory eye movements play an important role in a variety of tasks at all ages.  Anticipatory eye movements have been used to study expertise in soccer goalkeepers, object perception and expectations for "dynamic visual events" by babies, discourse comprehension in typical adults, sentence processing in adult readers, and the influences of language and knowledge about the world on adults' real-time visual attention.  These lines of research reflect an understanding that anticipatory eye movements are overt indicators of otherwise hidden attention shifts.  It's worth noting that not all anticipatory eye movements are microsaccades like the ones in Fried's ADHD study.  Some are smooth pursuit eye movements (the smooth, rapid eye movements used to track moving objects over a longer period of time).  However, saccades are often used for anticipatory eye movements, and the two overlap in neural areas, task demands, and the cognitive processes believed to be involved.

As Ellen Kowler put it:

"Work over the last 25 years has also converged on the notion that the saccadic system is inherently predictive, using pre-saccadic shifts of attention and signals representing planned saccades to encode the location we are about to fixate, and to prepare visual neurons, in advance, for the post-saccadic image. These predictions may be instrumental in processes ranging from the control of saccadic accuracy (by means of adaptive saccadic adjustments) to the weaving together of discrete glances in a way that gives us the impression of a clear and stable perceptual world despite the continual displacements of the retinal image produced by saccades."
Anticipatory or "look ahead" saccades occur during a variety of real world tasks, including text and sheet music reading, typing, looking at pictures of scenes, drawing, walking over difficult terrain, driving, sports, and cooking. In reading, saccades select a span of 7-9 letters or 1-3 notes for processing.  Typists keep their eyes about 1 second ahead of the currently typed letter.  Sketching involves rapid cycles of gaze shifts between the person being drawn and the drawing.  People instructed to walk in specific, effortful ways will look ahead by 1 to 2 steps.  When steering around a turn, driving instructors look at points their car will not reach for another 2-3 seconds, whereas their students, who have not yet learned to anticipate this way, look straight ahead instead.  Tennis players' saccades anticipated the bounce of a tennis ball by about 0.2 seconds, while cricket players can anticipate the ball by about 0.1 seconds.  When making tea or a sandwich, at the end of each action, the eyes move on to the next object about half a second before beginning the next action.  When there are two objects involved (e.g., a kettle and lid), multiple saccades and fixations must be made between the two objects.  In general, saccades followed by fixations proceed a step ahead of action.  This avoids reliance on visual memory.

All this anticipation is believed to help people do things better.  For example, they help people aim their reaching and grasping movements accurately.  Crucially, these saccades may improve performance on visual tasks and arm movements even when attention is directed elsewhere.

In general, we see, hear, act on, and think about things better when we are attending them.  Therefore, the visual system needs to predict what objects or locations in the visual field will be important and start attending to them before they do anything important.  Anticipatory eye movements are the mechanism for doing this.  As such, extra anticipatory eye movements should be an advantage.  They should increase the likelihood of attending the right thing and perceiving it accurately.  Or, at least, that is the picture presented by research on vision in the general population.

ADHD research describes anticipatory eye movements quite differently.  It describes them as "premature," "impulsive," and a sign of inhibitory difficulties--even when the tasks being studied do not involve inhibition of any kind.

So, is there any real difference between "premature saccades" and "anticipatory" ones, or are they just a negative and a positive label for the same behavior? I asked Sue Fletcher-Watson about this, and it appears that there is a difference, which is only apparent in studies designed specifically to test learning visual patterns. In studies like this, anticipatory saccades reflect an accurate prediction of where a stimulus will appear, based on learning; premature saccades are the eyes' tendency to flick around randomly looking for stimuli when a person gets bored.  Unless a person making premature saccades is lucky, their saccades will have no tendency to land where a new stimulus will appear, so the "success rate" should be measurably lower for premature saccades than truly anticipatory ones.

However, many of the ADHD studies under discussion do not appear to use this sort of learning task. Instead, they measure individuals' control over their eye movements during an experiment that is static and does not encourage or require learning. I suppose individuals could learn in such studies, and their learning could be measured and analyzed, but that's not what these researchers were doing. They might need to reanalyze their data to measure and compare learning in typically developing and ADHD groups. (And perhaps someone should).

Furthermore, I don't think that the ADHD researchers were even asking that question, trying to determine whether ADHD behavior was anticipatory or just premature.  Instead, they seem to be simply assuming "ADHD is a disorder of inhibition, so group differences must be due to an inhibition deficit."  This is an example of biased research, as explained by Morton Ann Gernsbacher--if you take away the labels of the group members, the interpretation no longer makes sense.  It also fails to take into account the more positive picture of anticipatory eye movements painted by the general vision literature.

Researchers on atypical development often say we should take typical development as a starting point, so let's do just that and see what it actually implies for vision in ADHD.

Let's say for the sake of argument we reanalyze the data or do new studies to make sure the eye movements actually are anticipatory--and they are.

Increased anticipatory eye movements in ADHD could have positive effects, which could be viewed either as a simple advantage or as compensation.  The trait may also carry a disadvantage.

When viewed as an advantage, it implies that people with ADHD may be better at noticing and directing their attention to changing and salient things in their environment.3  This ties in well with the theory (described to me by Jeff Gilger's research team) that ADHD vision is well-adapted to dealing with rapidly-changing, highly-salient stimuli, but ill-suited to maintaining attention on static and less motivating stimuli.

When viewed as compensation, extra anticipatory saccades could be seen as a way of increasing the likelihood of focusing on the right things when attention is hard to control by other means.  Anticipatory eye movements could also compensate for lack of visual working memory.  In the general population, people who have to copy drawings or models make lots of saccades to the thing being copied, instead of looking back at the object less and relying mostly on visual memory.  Since children and adults with ADHD may have less visual working memory than neurotypical people, they may need to make even more saccades.

However, there may be a disadvantage to the ADHD pattern.  Remember that we are effectively blind while making saccades or blinking.  The more saccades and blinks a person makes, therefore, the less time they spend taking in visual information from their environment.  This can be a disadvantage when performing a task that requires taking in lots of visual information over a long period of time (e.g., certain sustained attention tasks).

These interpretations of Fried's study are merely my speculations, based on putting aside assumptions about ADHD and instead looking at what we know about how vision works, in general.  So please don't quote them as if they were established research.  Rather, these represent a possible blind spot in ADHD research--and a set of hypotheses we can test.  Even if they turn out to be wrong, we will learn something about the strengths and weaknesses that come with ADHD.

Many thanks to Sue Fletcher-Watson for helping me figure out how to tell the difference between anticipatory and premature saccades and offering encouragement.

1 Interestingly, Moshe Fried himself has ADHD.
2  At least, so far as I can tell from the abstract and media descriptions from the study. This post will be updated when I get access to the full text.
2 Notice the obvious confound: improved performance on the second testing could have been due to practice taking the test rather than the stimulant medication.
3 Note that having an advantageous pattern of anticipatory saccades, which are unconscious and not deliberately controlled, does not preclude difficulty with more controlled eye movements.  In fact, a line of research indicates that ADHD people have difficulty controlling and inhibiting eye movements, just as they do with other behavior.  ADHD could simply involve deficits in controlled, but not necessarily uncontrolled, perception and behavior4.
4 Whether or not uncontrolled ("reflexive") saccades are also impaired in ADHD is still under debate.  Some studies seem to find slower, more variable responses, while others observe no difference from neurotypical peers.

Note:  The basic point about the strengths and weaknesses of anticipatory eye movements in normal development can be found in James Enns' The Thinking Eye, The Seeing Brain (one of the few readable, layperson-friendly textbooks I have ever seen).

Other citations reflect a limited amount of time to survey the role of anticipatory eye movements in ADHD and typical development, so they are mostly reviews and are necessarily incomplete.

  • American Friends of Tel Aviv University (2014). Involuntary eye movement a foolproof indication for ADHD diagnosis. Science Daily, 13 August 2014. www.sciencedaily.com/releases/2014/08/140813131055.htm 
  • Moshe Fried, Eteri Tsitsiashvili, Yoram S. Bonneh, Anna Sterkin, Tamara Wygnanski-Jaffe, Tamir Epstein, & Uri Polat (2014). ADHD subjects fail to suppress eye blinks and microsaccades when anticipating visual stimuli but recover with medication. Vision Research 101, pp. 62-72. http://www.sciencedirect.com/science/article/pii/S0042698914001187
  • Juliana Bittencourt, Bruna Velasques, Silmar Teixeira, Luis F. Basile, Jose Inacio Sailes, Antonio Egidio Nardi, Henning Budde, Mauricio Cagy, Roberto Piedade, & Pedro Ribeiro (2013). Saccadic eye movement applications for psychiatric disorders.  Neuropsychiatric Disease and Treatment, 9, pp. 1393-1409. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783508/
  • F.X. Castellanos, F. F. Marvasti, J. L. Ducharme, J. M. Walter, M. E. Israel, A. Krain, et al. (2000). Executive function oculomotor tasks in girls with ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 39, pp. 644-650.
  • D. Fiefel, R.H. Farber, B. A. Clementz, W. Perry, & L. Anilo-Vento (2004). Inhibitory deficits in ocular motor behavior in adults with attention-deficit/hyperactivity disorder.  Biological Psychiatry, 56:5, pp. 333-339. http://www.ncbi.nlm.nih.gov/pubmed/15336515/
  • Eileen Kowler (2011). Eye movements: The past 25 years. Vision Research 51:13, pp. 1457-1483 http://www.sciencedirect.com/science/article/pii/S0042698910005924 
  • Michael F. Land (2006). Eye movements and the control of actions in everyday life. Progress in Retinal & Eye Research, 25, pp. 296-324. http://www.cis.rit.edu/pelz/scanpaths/papers/eye-movements-every-day-life-land-2006.pdf
  • Neil Mennie, Mary Hayhoe, & Brian Sullivan (2006). Look-ahead fixations: Anticipatory eye movements in natural tasks. Experimental Brain Research http://www.ski.org/Renninger_Lab/BSullivan/MennieEtAl_LookAheadFixations2006.pdf
  • S. H. Mostofsky, A. G. Lasker, L. E. Cutting, M. B. Denckla, & D. S. Zee (2001a). Oculomotor abnormalities in attention deficit hyperactivity disorder: A preliminary study. Neurology, 57, pp. 423-430.
  • S. H. Mostofsky, A. G. Lasker, H. S. Singer, M. B. Denckla, & D. S. Zee (2001b). Oculomotor abnormalities in boys with Tourette syndrome with and without ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 40, pp. 1464-1472.
  • Nadia N. J. Rommelse, Stefan Van der Stigchel, & Joseph A. Sergeant (2008). A review on eye movement studies in childhood and adolescent psychiatry. Brain & Cognition, 68, pp. 391-414 http://www.fss.uu.nl/psn/web/people/personal/stigchel/rommelsereview.pdf 
  • N. N. J. Rommelse, S. Van der Stigchel, J. Witlox, C. J. A. Geldof, J. B. Deijen, J. Theeuwes, et al (2008). Deficits in visual spatial working memory, inhibition, and oculomotor control in boys with ADHD and their non-affected brothers. Journal of Neural Transmission, 115, pp. 249-260.
  • R.G. Ross, D. Hommer, D. Breiger, C. Varley, & A. Radant (1994). Eye movement task related to frontal lobe functioning in children with attention deficit disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 33, 869-874.
  • Alexander C. Schutz, Doris I. Braun, & Karl R. Gegenfurtner (2011). Eye movements and perception: A selective review. Journal of Vision 11:5, 


Things You Can Do to Help Disabled People that Don't Cost a Cent (Guest Post)

This list of ways to respect and offer an accessible environment to people with disabilities is reposted with permission from Neurodiversitysci, and includes all comments with attributions.  (Where no attribution is given, the point comes from the original post by Neurodiversitysci; where an attribution is made, it comes from another person).  I've broken the list into a few categories to make for easier reading and corrected some typos.

Neurodiversitysci says, "This list should probably have a huge disclaimer of YMMV [your mileage may vary], since disabled people often have different experiences and live in different social environments with different social barriers. It's pretty much guaranteed some things won't apply to everyone. More importantly, some of the points on the list are based on conditions and experiences I have personally, while others are just based on listening to people."

Also, disabilities (as defined here) include: developmental and learning disabilities (e.g., autism, dyslexia, intellectual disability); chronic illnesses (e.g., MS); mental illness (e.g., depression, Bipolar Disorder, schizophrenia); and physical disabilities (e.g., blindness, deafness, inability to walk).


  • Do not talk about an obviously disabled person in front of them as if they can't hear you.
  • Do not talk to a disabled person's companion instead of them.
  • Ask permission before touching people, or their wheelchairs or other equipment, even if you want to help.
  • Ask permission before touching people's service animals. "Service animals are just that: animals trained to serve the needs of people with disabilities. Please do not distract them from doing their jobs. If you want to pet them or interact with them, ask their owner!" -Lightles
  • Ask disabled people about their lives and really listen to their answers. (Within reason. For example, asking people personal questions about their sex lives is rude unless you're very close to them and they've communicated they're OK with that).
  • Listen to what they say, whether they are speaking, writing, typing, using text to speech, using a letterboard, using PECS, gesturing, using sign language, or using any other form of communication. People who can't speak can still communicate.
  • Understand that "people with disabilities are, first and foremost, people, not saints or martyrs. We have virtues, faults, interests, dreams, and ambitions that have nothing to do with the things our bodies and minds are or are not capable of doing.  Please remember this and treat us accordingly." -Lightles
  • "Don't assume that disabled people...must have miserable/inferior lives. We are different, not lesser." -QueerAutisticMRA
  • Understand that disabled people don't just need friends, they can be friends. [Inspired by Judy Endow].
  • Stand up for people you see getting bullied.
  • When talking to someone who has trouble speaking or stutters, and takes a long time to speak, please wait for them to answer. Don't keep repeating the question or pressure them.  Yes, if you are like me and your mind is going really fast and you forget what people are saying if they take too long, it can be hard to be patient. Do it anyway.
  • When talking to someone who cannot say a word correctly (or at all), it doesn't help to keep asking them to say the word over and over again until they get it right. It will likely frustrate them, and they may still be unable to say the word; in fact, the stress and pressure might make it harder. [Astroayla].  (This point assumes you're not their speech and language therapist.  Even so, there are probably better ways to handle the situation).
  • A disabled person with intellectual disability who has the academic skills or IQ of, say, a 7 year old, does not actually have the mind of a 7 year old.  They have different life experiences, needs, stages of life, bodies, and so on.
  • Understand that a disabled person's talents, however esoteric, are real, not unimportant "splinter skills."
  • "Do not tell anyone with any kind of disability or illness that it's not real. Nothing makes it more apparent that you don't actually care about or respect a person than to tell them that their illness/disability isn't real...Like I'm going to take the words of some guy I barely know over my therapists and doctors." -Wojojojo 
  • Do not tell a person with ADHD or mental illness that they should not be taking medication. This is a personal decision. Furthermore, since medications often have wide-ranging effects on bodies and minds and unpleasant side effects, most people taking medications have thought through the issue, done a cost-benefit analysis, and decided that functioning better is worth it. Their decision should be respected.
  • Conversely, do not tell a person with ADHD or mental illness who is not taking medication that they should be [Suggested by Lichgem and Shinobody].
  •  Not all disabilities are obvious or visible to the naked eye.  This is true for physical, mental, and emotional disabilities.  Sometimes this includes difficulty with things like standing for a long time, and requires accommodations like using the elderly/disabled seats on a train.  Do not assume that someone you see doing this is faking. [Lawless523].  Also, if such a person, without glasses/cane/wheelchair/etc., tells you they have a disability, accept this and treat them with the consideration you would show to a person with an obvious disability. [Lightles].
  • "Think long and hard before complaining about the "special privileges" people with disabilities get. Yes--the parking places reserved for the disabled are closest to the door of your favorite restaurant, but that's because the people who need the space find walking to be difficult, painful, or impossible. The people who use these spaces would almost certainly rather park further away than have to use a wheelchair." -Lightles


  • Recognize that failure to make eye contact does not necessarily mean someone is lying to you. It could simply be uncomfortable for them.
  • Recognize that unwillingness to go to loud, crowded bars does not necessarily mean someone isn't interested in socializing with you. They may simply find the noise and crowds painful, or be unable to understand what you're saying in that sort of environment.
  • Recognize that a person can need time alone and it doesn't mean they're avoiding you.  It's just something they need so they can function at their best.
  • If a person does not recognize you, do not assume they don't care about you. They may be face-blind.
  • If a person does not remember your name, do not assume they don't care about you. They may simply have a bad memory. [Autistic Velociraptor].
  • If a person does not remember your birthday (or other major names, numbers, or dates), don't assume they don't care about you (or whatever it is they've forgotten). They may simply have a bad memory.
  • If someone has difficulty spelling, or using the appropriate jargon/terminology, do not assume they're stupid.  Some people have difficulty with these aspects of language. You may need to paraphrase some "jargon" for them.
  • Understand that a person can be working incredibly hard to do something and may still not perform as well as you'd like them to, as well as the average person would, or as well as the situation demands. They are still trying, and it hurts when you tell them they're not.
  • Recognize that even if a person is unable to respond in a way you can understand, they can still hear you. Don't suddenly start talking about everything you hate about them, or wave your hand in their face. Instead, talk to them the way you normally would. That doesn't mean using an overly exaggerated "I'm pretending everything is normal" voice, which they may be able to see through even though they can't communicate.  It means talking to that person the way you'd talk to anyone else. Although they may not be able to tell you right away, it makes all the difference in the world. "I cried the first time this happened to me. Even my friends had never done it, up to that point." -Youneedacat
  • Colorblindness affects more than just knowing what color something is. To a colorblind person, colors they can't see will look the same if they have the same degree of lightness/darkness, which can change the level of contrast between things. To a red-green colorblind person, for example, a red rose on a green background can blend in instead of contrast starkly, and the Chicago CTA El map can be hard to understand.  Understand that something that stands out and seems obvious to you may literally not be visible to a colorblind person.
  • Understand that for some people, particularly autistic ones, it may be inappropriate to read more into what a person says than what they literally say. "If I ask you to skip a song on your playlist because there's a high noise in it that bugs me, all I am saying is what I just said. I'm not implying that you should let me pick the music. I'm not dissing your taste. I'm saying there's a high noise in that song that bugs me. That's it, that's the whole meaning." -Jumping Jack Trash
  • "Also, when we ask for clarification on something, please provide clarification. It might be obvious to you what you mean, but it might not be to everyone. In the case of humor, we're not trying to spoil the joke. We might even get that you just said something that is supposed to be humorous, but we don't necessarily know WHY it's humorous. That's why we're asking, so we can get the joke next time." -I Has a Politics


  • Every public place does not need to have loud, blaring music and TVs with flashing screens
  • "For the love of God, don't touch people without asking! It may not seem like a big deal to you...[and] I understand sometimes it just happens, rushing and brushing against someone, but some of this is either intentional or could easily be avoided. Not everyone needs or wants a hug from someone they don't know. In fact, it might be a huge stresser." -Nuclear Vampire
  • If you blog, put bright, flashing images that can trigger seizures under a cut so that people with seizures can avoid looking at them.
  • If a job can possibly done without a person driving, don't require candidates to drive or have a driver's license.  Don't interview candidates and then reject them because they can't or don't drive.  Lots of people with disabilities cannot drive safely, including those with low vision, slow reflexes/response time, and some with autism or ADHD.
  • If you are talking to a deaf person, make it easier for them to lip-read by facing towards them while looking at them, and not covering your mouth with your hands.
  • If you are talking to someone with hearing impairment or auditory processing disorder, it is more helpful to slow down, face them, or rephrase what you're saying than to just speak more loudly.
  • Some disabled people have difficulty understanding nonliteral language such as metaphors and idioms (e.g., "a stitch in time saves nine"). If you're talking to someone like this, try explaining what you mean by these figures of speech, or just avoid them. Also, if nonliteral jokes confuse or upset them, you should avoid them and especially avoid using these jokes on purpose to make fun of them [Antimone Grey].
  • If you're talking to someone who has difficulty understanding nonliteral language, do not use only nonliteral language to convey your point. "Say what you mean...don't use hints, implications, analogies, hyperbole, or metaphor in place of actual information. Whether analogies, hyperbole, etc. can help in illustrating your point depends on the individual; many of us are fine with figurative language in a lot of cases, especially if we have context to place the phrase in. But if you want us to know a thing, tell us the thing itself instead of or in addition to talking around it." -Jumping Jack Trash


  • Don't tell them "but you look so normal!" Or "you don't look like [x]." It will not be taken as a compliment. [Rosslyn Paladin].  But, if they accomplish something you know they were working really hard to do, it's great to compliment them on it.
  • "Don't tell someone they're 'not really ___' because they don't have something in common with the average ___. For example, I'm not bothered by loud jittering noises; in fact, anybody who knows my taste in music knows that I love them, but that doesn't make me 'not autistic' because some people who are also autistic ARE bothered by jittering noises...not everyone with a disability is the same." -Blind Skywatcher
  • "Please don't ask if they are getting better, or will get better." -Little Red Chucks.  Most disabilities and chronic illnesses are permanent, while mental illnesses tend to be long lasting, and even if a person recovers, can recur over the course of a person's life.
  • "Please do not assume that a child's disability is the fault of their parents or carers." -Little Red Chucks.  Except for genetics (e.g., a disabled parent having a child with the same disability) or extremely rare and specific cases, like Fetal Alcohol Syndrome, a child's disability is not their parents' or caretakers' fault. 
  • If someone has a major medical problem, disability, or chronic illness, then just eating some special healthy diet or exercising more isn't going to cure it. It might help, it might hurt, it might do nothing, but the person has probably heard the advice before, and unless you're their doctor, it's none of your business in any case.
  • A person with OCD knows that checking or counting or whatever compulsive action they perform won't really prevent disaster from happening, it's just a compulsion. That doesn't stop them from feeling the need to do it anyway. A person with anxiety may know that at least some of their fears are irrational or unlikely to occur. That doesn't stop them from feeling anxious. A person with trichotillomania may know it hurts them to pull out their hair or pick at their skin, but they have difficulty stopping themselves anyway. A depressed person may know that they would feel better if they got out of their house and talked to people, but that doesn't make them feel any more up to doing those things. A person who hallucinates may know the hallucinations aren't real, but that doesn't make them go away or feel less upsetting. Do you see the pattern? You can't cure people with mental illnesses by telling them they're being irrational or hurting themselves. If it were that easy, they'd have cured themselves already.
  • Telling people they're inspirational simply for living their lives or getting out of the house is not a compliment. It's telling them that you think their lives are so unbearably awful that just living is an inspiration--which is insulting. It's different to tell them you admire them if they do something truly impressive, or that you know is hard for them personally and they worked hard to accomplish it.
  • Accept stimming.
  • "Do not play the "how many fingers am I holding up?" game with a blind or visually impaired person. It's just rude." -Lightles
  • Disabled people having a meltdown look like they're throwing a tantrum or being aggressive, but they are not. People can have anger meltdowns [Blackwinged Rose], but people assume all meltdowns are about anger, and that's not necessarily true--they're often caused by terror.  Having a meltdown means a person has gone into fight or flight. The best thing you can do is remain calm yourself and help them calm down. It may help to keep your distance, keep your voice low and calm, let them retreat to a safe place if they know to do that, or remind them to do so if they forget.  Reasoning with them won't work well because they're unlikely to be able to hear and understand you. The worst thing you can do is start yelling yourself, threatening them, be violent to them, cut off their escape route, or get right up in their personal space.
  • Most of all: even the identical disability affects different people differently. The preferences of the specific person you're interacting with take priority over any generalized rules, including this list! "There's no catch all method to treat every disabled person appropriately to their own desires. Just try to exercise the best judgment you can and ask before assuming. They often appreciate your intentions even if your assistance isn't needed. They're a lot more capable than people give them credit for." -Spud Fuzz

Comments are welcome, and further ideas will be added to this list. Advice relating to physical or intellectual disabilities would be particularly welcome.


An Open Letter to Jeffrey Howe

Dear Jeffrey Howe,
I read your piece today in Motherlode.  I wanted to comment and speak to you directly, but didn't have an account on the site, so I will write to you here and hope my readers here and on Twitter will share it with you.

I am the older sister of a young man who was diagnosed on the spectrum as a child and has not lost the diagnosis. I am also a cognitive neuroscience researcher in training, and hope to study people on the autism spectrum in the future.

I was pleased to see you listened to the autistic adults who wrote to you--people who share some experiences with your son, and who, if all goes well, he might even resemble some day.  Not all parents are willing to do this.  It's not easy to hear that you might inadvertently be doing something that might hurt your child, and embarrassing to realize that you didn't imagine autistic people might read what you wrote.  But you listened and acknowledged these mistakes, and that takes empathy and integrity.

But I was disappointed with where you ended up.  You said:
"In the same way I hope that the other patrons at our local diner will accept the child doing a headstand in our booth, I hope that autism advocates accept that we require every meager word at our disposal to describe our unique experiences...Let us accept words for the blunt, imperfect tools that they are."*
First of all, please understand: you can write about your child's difficulties, and the effort and expense of raising him, without saying things that autistic readers find dehumanizing and hurtful.  You've already done it, in fact.  You said:

"Last year Finn climbed out his bedroom window, falling two and a half stories, breaking his pelvis and fracturing two vertebrae. He had pushed his stuffed animals out the window, and lacking any understanding of gravity or height, he simply wanted to join them in our yard... 
He used to point to an object he desired, his one concrete method of communication. Now he uses American Sign Language for music and movie and dog and shoe and food and drink and up and help and stop and wait and candy. He is beginning to shake his head for no and nod for yes, and when I look into his eyes I see now that he loves us as fiercely as we love him. He only rarely bites us anymore, or wraps an angry hand around his sister's hair."
A very evocative description of Finn at two points in his life, and no offensive language in sight.

The thing about labels like, yes, "low functioning," is that they are not only hurtful but vague.  What does a low functioning person look like?  A non-speaking child who is constantly hugging, smiling at, and initiating interactions with their parents could be called low-functioning.  So might a child who can speak but has frequent meltdowns, or whose independent living skills are so poor they cannot be safely left alone for long and cannot cross the street unaided.  A child with low IQ might be called low-functioning, but so might an average-IQ child who simply cannot fit into a mainstream classroom or who has all the DSM autism traits to an extreme degree.  Wouldn't it be better to describe what your child is actually like, what he can do and can't do right now--as you've started to do here?  Wouldn't that better achieve your goal of describing what life with him is like?

I should also note that not all the negative words you've singled out ("nonverbal," "impaired," and "low functioning") are all harmful, so your palette is less limited than you may have feared. For example, I've yet to hear anyone object to "nonverbal," which is a simple statement of fact--that a person cannot speak.

Suppose, though, that hurtful labels actually were a sufficiently precise way to describe life with your child.  I still don't think achieving this description is worth the pain it would cause.  Let's compare the costs and benefits.

If you use the language you like, you will be happy at expressing how you feel, and some of your parent readers will feel validated and cheered.  On the other hand, you will have, unwittingly, reinforced views of autistic people that, when acted on, cause a lot of pain.  More directly, any autistic people reading will wince, feel hurt and angry at best and outright traumatized at worst.  Many have some very painful histories with terms you use such as "low-functioning."  They have experienced abuse from therapists and even parents, have been treated as if they weren't "really there," and sometimes been in institutions.  When people deemed "low-functioning" go out in public, others address their nonautistic companions instead of them, or talk about them in front of them as if they weren't really there.  People deemed low-functioning are denied a complete education.  And if they are deemed too "severe" or "low functioning" by too many people, they may get sent to centers of last resort, like the JRC, where they are electro-shocked into submission.

Saying someone is "unable to communicate" or "in their own world" probably doesn't lead to as much outright abuse as "low functioning."  But here's the thing--people unable to speak, with limited gestures, still do try to communicate, through the only means available to them--behavior, such as flopping down in the middle of the floor, or flapping their hands, or biting themselves, or even just screaming.  Not the ideal communication method, we can all agree--but how often do parents, clinicians, or teachers attempt to interpret the meaning of this behavior, and how often do they simply call it a behavior problem and attempt to squash it?  These severely disabled kids, thus, are the ones who are most hurt by words like "unable to communicate," not "quirky Intel programmers."  And people who seem "unable to communicate" don't just communicate through challenging behavior, either.  They communicate through touch--they lead parents to something they want to show them; they gently touch their parents to comfort them.  Lacking the ability to create sentences of their own, they communicate using other people's words--what researchers call "echolalia."  Maybe there are a few people utterly unable to communicate, maybe your child is even one of them, but I would bet that most kids whose parents describe them as unable to communicate are, in fact, trying to communicate, but their atypical signals are being misunderstood or ignored.  I suppose eventually, such kids might give up as they get older and realize they won't be understood, but that's not everyone.  And while autistic kids are often focused on very different things than we are--the toys they're lining up, or the sensory stimuli or special interests that absorb their attention to the exclusion of all else--that doesn't mean they're "in their own world."  In fact, it's dangerous to assume autistic kids are "in their own world" because it's just a step from there to "they're not aware of anything that's going on" and from there, only a step to "it doesn't matter what we do or say to them, because they won't care anyway," and that's when teachers and therapists and others start to abuse.  And if we think autistic kids are "stuck" in their own world, how much effort will we make to integrate them into our schools or public places?  Autistic kids live in the same world we do, however differently they may perceive it.

So if you use words like "low functioning" or "unable to communicate" or "stuck in his own world," you could hurt any autistic people who may be reading, while contributing to the assumptions that make people abuse them and excuse that abuse.  On the other hand, you could please some parent readers in need of validation.  On any reasonable cost-benefit analysis, using expressions like these just isn't worth it, even if they were useful. 

I wish that language were as neutral and unimportant as you make it out to be when you say you hope "that autism advocates will accept that we require every meager word at our disposal to describe our unique experiences...it comes down to tolerance."  You may have noticed that as a parent, most people in the general public see you as an authority on autism.  They may even see you as more of an authority, and listen to you more attentively, than they would an autistic person.  This power to shape opinions means, unfortunately, that every word you say carries immense weight.  You have the power to create a more hospitable world for people with your son's diagnosis--or reinforce the same prejudices that currently make life harder for them.  Look at it this way: your son already carries a burden other children do not, because of his disability.  Does he need to carry an additional burden of stigma and the presumption of incompetence from everyone around him?  It may be hard to lighten the burden of the disability, so it becomes all the more important to ease the burden of stigma.  I have heard calls to stop disagreeing about words in the interests of "unity," but "unity" should not come at the expense of those who are most disabled, and do not have the words yet to speak out against what hurts them.

Lastly, please understand that however "abstract" the distinction between disability and disease may seem for you, this is because you yourself do not have autism and can afford to ignore the issue.  Autistic people do not have that luxury, which is why those who can write and blog discuss the issue so much.  It directly affects their lives and their self-worth.  And from a practical perspective, there is a huge difference between therapy that attempts to make a child look exactly like his peers and therapy that doesn't worry about appearances, aiming only to teach skills.  There's an even bigger gulf between therapy that teaches children to achieve better results with the brain they have and therapy that attempts the impossible task of turning their brain into a very different type of brain.  Dismissing this issue as unimportant would be myopic and unwise.

I hope Finn continues to grow and learn to communicate better, and that his and your lives get easier.  I also hope that he will never feel wounded by what you have said or written about him.

You may also enjoy reading books written by nonspeaking autistic young people.  You might want to start with "The Reason I Jump" by Naoki Higashida, who uses a question-answer format to address questions people often have about what it's like to be him and why he behaves the way he does. "I Am Intelligent," by Peyton Goddard, is a harder and more upsetting read, but worth it, I think.  I personally wasn't crazy about Tito Mukhopadyay's style in "How Can I Talk if My Lips Don't Move?" but it brings his very different perceptual world to life like nothing else, and you'd probably enjoy seeing how his mother, Soma Mukhopadyay, taught him.  My favorite, though, is "Ido in Autismland: Climbing Out of Autism's Silent Prison" by Ido Kedar.  It's telling, I think, that he characterizes his autism as a prison and still seems more hurt by the way others treated him and denied him an education. All are very different from each other and probably from your son, but they offer an amazing glimpse into the world of people who were called "low functioning" and "unable to communicate," and offer a basis for hope and faith.

*By the way, this is a false analogy.  The worse damage Finn's headstand can do to other restaurant patrons, on the single occasion where they see him, is a bit of distraction or annoyance.  Whereas the worst damage certain words by parents can do involves eliciting traumatizing memories of abuse and reinforcing the exact prejudicial attitudes that caused that abuse in the first place.


The difficulties of early diagnosis: Insights from Sally Ozonoff

If you've read any early autism studies, you've probably heard of Sally Ozonoff.  At UC Davis's MIND Institute, and working with 11 other sites across the country, she heads up prospective studies looking for ways to diagnose autism earlier. At Northwestern yesterday, she gave an overview of her major findings over the past ten years.  What she said will disappoint people hoping for earlier diagnosis for their children (or wishing they'd been diagnosed earlier themselves), but will please those who see early diagnosis as leading to interventions that do more harm than good.

According to the latest CDC report, the average age of diagnosis is the same as it was two years ago--53 months (or about 4 1/2 years).  Yet parents are first concerned about their child's development at an average of 18-19 months.  Parent reports certainly have flaws, as most are not trained in child development and are looking at the big picture rather than the specific details of behavior that might provide the best clues (e.g., frequency of pointing vs. other gestures).  In particular, they might reliably distinguish a child with atypical development, but not be able to tell if autism is the appropriate diagnosis--even trained psychologists seem to have difficulty with this.  However, Ozonoff thought, if parents can identify potentially autistic children as early as 18 months, shouldn't psychologists with all their developmental training and research tools do at least as well?

The methods used for investigating the earliest signs of autism have changed.  Originally, there were two main sources of information: interviews with parents and home videos.  Parent interviews attempted to get the most detailed information possible by asking about "landmark events," memorable things that happened when the child was a particular age.  If a family traveled to visit the grandparents when the child was 12 months old, for example, the researchers would ask them to picture it and would ask if, for example, the child was toddling around the kitchen, or pointing to items of interest at Grandma's house.  The information provided seems to be accurate, but not fine-grained enough.  Home videos are better because you can watch the behaviors unfold yourself and count how often behaviors of interest occur.  However, they take hours to analyze, and videos may not include relevant, but less presentable behavior--e.g., Grandma will not want to see a video of Johnny failing to respond to his name twelve times in a row, or having a meltdown.  So now, Ozonoff's team takes a different approach.  They identify so-called "high risk siblings," babies who have an older ASD sibling.  The matched control group is babies who have no first, second, or third degree ASD relatives (that means no grandparents, aunts, uncles, or cousins--which is increasingly hard to find these days).  These babies are first seen at 6 months old, and are followed up at least at 12, 18, 24, and 36 months.  At 36 months, all are tested for ASD or other atypical development and assigned to a diagnostic category.  This approach allows Ozonoff's team to retrospectively look at how ASD children developed over time, and at what point they first diverged from peers with typical or other atypical development.

The biggest problem for such research is separating ASD babies from other atypically developing peers, so let's talk about how "other atypical development" was defined.  First, babies who were within 3 points of the ADOS cutoff for ASD, but still below it, were "atypically developing."  Second, babies who scored at least 1.5 standard deviations below the mean on cognitive, verbal, or motor skills on the MSEL (a standardized direct observation test) were atypically developing.  The resulting group could be expected to be a heterogeneous mix of children with subthreshold autism traits and those with various developmental delays or learning disabilities.

I had expected Ozonoff's team to look only at socially relevant behaviors (things like eye contact, looking at faces, responding to name, joint attention, etc.).  However, they cast an impressively wide net.  They looked at sensory and motor skills--babies' abilities to gradually follow a moving object with their eyes (called "smooth pursuit"), and their ability to integrate auditory and visual information when listening to speech. Even head circumference was measured.

Unreliable Early Markers
Most of the measures examined didn't differ in high and low risk babies.  For example, high risk babies were just as responsive as low risk ones to the "still face" paradigm, where parents interact normally with their babies for a while then suddenly stop interacting, with a completely blank face.  Babies, who were previously smiling and making eye contact with the parent, now start looking away, losing positive affect, and sometimes become distressed.  When the parent returns to playing with them, though, babies normally return to making eye contact and smiling at the parent.  High-risk babies, as a group, show the exact same pattern.

Another behavior looked more indicative of autism, but didn't pan out.  High risk babies were more likely to look at the mouth than low risk ones, who looked at the eyes1.  However, although 10 out of 11 kids (91%) who focused on the mouth were high risk babies, most of the high risk group still looked mostly at the eyes.  Furthermore, none of the mouth lookers turned out to be autistic, with most typically developing.  Meanwhile, all four with ASD tended to look at the eyes rather than the mouth.  While looking at the mouth does not predict autism diagnosis, but it does predict expressive language skills, on both a direct test (MSEL) and a parent questionnaire (McArthur CDI).  (This is a pretty common relationship in autism language research, but Ozonoff said that as a clinical psychologist, she was unaware of it.  She talked a lot about being a clinical psychologist and how she hoped to get other perspectives from her hosts in the Northwestern Communication Sciences and Disorders department).

Ozonoff's team also looked at children's response to their name, because this is the most common concern parents have.  Again, it wasn't a reliable marker.  Again, high risk babies were more likely not to respond to their name than low risk ones, but only 14 high risk babies failed out of 101 (14%).  Of these 14, 5 turned out ASD (36%), 6 (43%) atypically developing, and 3 (21%) typically developing.  Meanwhile, this marker missed 4 ASD and 22 atypically developing babies.  The best thing one can say about failure to respond to name is that it can identify atypical development in general (80% of such children are atypically developing), but not ASD in particular.  And even for atypically developing kids, most were not identified this way.

So, at what point were researchers able to distinguish the autistic babies?  There were no group differences at all at 6 months, and differences on almost every measure by 12 months.  Even so, only one baby was diagnosed at 12 months, 15% by 15 months, and under half by 18 months.  The average age of diagnosis was 24 months--about the age at which these experienced clinicians would feel comfortable making a diagnosis anyway.

What changes from 6 to 12 months in autistic babies?
The change from 6 to 12 months was dramatic enough that Ozonoff's team explored further with their another group of babies, adding an observation in the middle at 9 months.  Here, she found the only significant results so far.

At 6 months, ASD babies looked, smiled, and vocalized at parents and experimenters just as much as their peers.  However, from 6 to 12 months, their frequency of looking dropped steeply, their smiling declined slightly, and their vocalization remained the same.  Meanwhile, typically developing babies dramatically increased their rates of looking, smiling, and vocalizing at interaction partners.  This pattern existed across the entire group, not just the roughly one third estimated to have lost language or social interaction skills.2  Furthermore, this finding was based on a direct count of looks, smiles, and vocalizations during a real-time interaction, not a standardized measure--it captured the behavior itself, not just the relative frequency compared to a normative group.

Experimenters and parents were asked to rate their child's frequency of looking, smiling, and vocalizing at the end of each session based on general impression.  Experimenters reported the same drop as the coders did, and so did 71% of parents.  Interestingly, 29% of ASD parents reported rates of looking, smiling, and vocalizing that stayed the same from 6 to 12 months, and did not differ from ratings for typically developing babies.  Ozonoff's team assumed these parents were simply bad reporters, as these babies ended up with a diagnosis of ASD, but this is a problematic assumption and we'll talk about why later.

A similar pattern held for synchronous behavior, which was defined as either looking/smiling/vocalizing at each other at the same time, or responsively (with the response following within 3 seconds).  In fact, at 6 months, ASD babies were more in sync with their parents than typically developing peers.  By 12 months, however, ASD babies were less synchronous while typically developing babies had become more so; typically developing babies were now more synchronous than ASD ones.

There's another difference that I, personally, find more interesting.  At 12 months, babies were given a variety of toys to play with, including a shiny round lid, which had two sides that looked different from each other.  Typically developing babies, given that lid, liked to put it on their face or in their mouth, drop it, or bang on the table with it.  They seemed to enjoy the noise this made, and be focused on how the object felt, moved, and sounded rather than how it looked.  They also were less focused on the toy, looking more frequently at the experimenter and around the room.  ASD babies were more focused on the toy, with fewer looks elsewhere; they were more likely to attend to it without interruption for 10 seconds at a time.  They also had a different pattern of playing with the toy.  Unlike the typically developing babies, they actually noticed that the two sides of the lid looked different.  They were more likely to rotate the objects to stare at the different sides; more likely to hold it up close and squint at it; and more likely to spin it, or drop it and watch it wobble. In addition to this set of visual behaviors, they still engaged in the more tactile and auditory play behaviors the typically developing babies preferred.  Each of these visual behaviors, and their composite, were highly predictive of group membership; crucially, they were much less common in other atypically developing babies (but given the low base rate of autism in the population, this is still unlikely to enable reliable early diagnosis).

The differences in play here were fascinating because they are among the earliest evidence of autistic people's fascination with visual stimuli, particularly things that spin.  The differences from other atypically developing babies also surprised me, because atypical sensory processing occurs across all developmental disabilities.  It would be interesting to know whether, across the lifespan, fascination with shiny, spinning things really is more common in autism than in other conditions with atypical sensory processing.

The problem of distinguishing ASD babies from atypically developing ones...again
Atypically developing kids could be identified either by developmental delays on the MSEL, or by high but subthreshold ADOS scores.  76% were identified based on high ADOS scores, 14% on high MSEL scores, and 10% on both--meaning that 86% could be considered to have the "broad autistic phenotype" and only 24% could be considered developmentally delayed.

Such a group makes it all the harder to separate autistic from other atypically developing kids early on, because the autistic kids aren't a different type of disabled child, they just have more extreme versions of the same traits.

Are atypically developing kids just autistic kids who received early intervention?
The atypically developing group's rate of early intervention wasn't significantly different from typically developing participants.  This was despite Ozonoff's team's aggressiveness in informing their parents about the risks of ASD diagnosis and the benefits of early intervention for this group. Thus, these children's failure to develop ASD has nothing to do with being helped by early intervention.  This is a point you're not likely to see discussed much--Ozonoff herself only brought it up in response to a question about diagnostic reliability in her studies--so I think it's important to emphasize.

Questions and Problems
1. How unreliable are parents, really?
Almost 30% of parents of autistic kids rated them as displaying the same rates of basic social behaviors as their typically developing peers.  Ozonoff assumed these were poor reporters because these children were later diagnosed with ASD.  But she did not say whether she examined the measured rates of social behaviors in these kids to see if there actually was any difference.  And in fact, it's possible that these kids really did have high rates of social looking, smiling, and vocalizing, while still being autistic.  There are several ways this could happen.

First, these babies could have mastered these particular social behaviors, which are early developing and do not require complex motor skills or advanced concepts.  Yet, they might have more difficulty with other skills measured by the ADOS, such as pointing, triadic joint attention (between a person and an object), or conversation.

Second, the babies could have been inconsistent, as often occurs in atypically developing populations. Whatever their real level of social communication skills, they performed well in one context (interaction with parents or experimenters) but not in another (the ADOS examination).

Third, the babies could have diverged from typically developing kids in social communication behaviors later than 12 months.  They may have had typical social behaviors at 12 months, but different enough to receive an ASD diagnosis by 36 months.

This would appear to be a case where the assumptions of a discipline (i.e., that clinical psychologists, as experts, know more than poor, ignorant parents) get in the way of a truly scientific examination of a question (i.e., testing other possible explanations for an inconsistent set of results).

2. The definition of synchrony
First, the good news.  Unlike the "reciprocity" studies I've discussed in an earlier post, this study did measure the behavior of parents as well as their children.

The bad news: synchronous behavior was defined as either displaying a social behavior at the same time as parents, or as a response within 3 seconds.  But what if ASD babies are slower to respond?

This could be for any number of reasons.  If they are focusing their attention on one thing (perhaps a toy both are playing with), they may be slow to shift their attention to something else.  Slow shifting of eye movements and attention have often been found in autistic kids and adults, as discussed in a previous post.  If they have to shift their attention first, that could delay the response.  Second, slow responses in general sometimes occur in autism, particularly when speech is required.  These 6-12 month olds aren't using speech.  But if vocalizations for them work in a similar way to speech for older people, one might expect their responses to take longer than 3 seconds.

So, are ASD babies really less synchronous at 12 months?  Maybe.  I'd be more confident in this result if the time window for response were a little wider.

3. Assumptions I don't like
Like many clinicians--including most of the audience at her talk--Sally Ozonoff assumes that any early intervention is a good thing, no matter what it consists of. That if early enough, intervention can even prevent all the characteristics of autism from emerging at all.

She is obviously not familiar with the borderline abusive therapies that some children receive, perhaps because there is little awareness for bad autism interventions.

She also loves the Autism Speaks parent kits, particularly the "first 100 days" one, and actually recommends them to parents.  Full disclosure: I have been working with parents and autistic adults to make an alternative that would be more helpful, and less depressing.

The Upshot
In this study, children received a diagnosis at an average of 24 months, which was a lot earlier than in the general population (53 months).  However, with all the behavioral and electrophysiological data they collected, they still weren't any faster than they would have been using clinical judgment alone.

She's been studying high-risk babies since 2003.  All this time and money has brought us nowhere near having a method that could be widely used to identify autistic babies and toddlers, much less distinguish them from similar atypically developing kids.  At this point, the effort seems almost pointless.

There is, however, one exception.  Babies with an autistic sibling have much higher rates of an autism diagnosis.  Across the 12-site Baby Sibs Research Consortium, which tested 664 high-risk babies, 19% were diagnosed with ASD.  The rate was particularly high in males, with about 25% of males and only 9% of females receiving an ASD diagnosis.  The rate was higher still in families with multiple ASD siblings, where almost 50% of males and about 18% of females diagnosed with ASD.

Interestingly, all sorts of much-touted risk factors didn't make a difference in this large sample.  The sex and functioning of the older ASD siblings didn't matter.  The younger sibling's age at enrollment didn't matter.  The birth order, parent age, and demographic variables--even ethnicity and SES3--didn't affect diagnosis rates.  Only the child's sex and the number of ASD older siblings mattered.

Therefore, Ozonoff argued, we should be paying more attention to screening younger siblings than we are, especially boys and those with multiple ASD older siblings.  Pediatricians should know that the ASD rate is much higher in this group and watch their development particularly closely.4

So there you have it: early diagnosis is nowhere near existing in reality, except, perhaps, for younger siblings.
1 Notably, Ozonoff's study measured looks to the face in this and the still face paradigm in an unusual and somewhat artificial way.  The mother was in another room and her face was projected onto a screen in front of the baby, so that a camera could more easily measure where the baby was looking.  Most babies still had typical responses to the still face in this setup, which suggests that they still thought they were interacting with their mothers.
2 This particular study did not measure regression, but Ozonoff reported that other studies estimate it at about 1/4-1/3 of the autistic population.  
3 The lack of ethnicity and SES differences in diagnostic rates surprises me.  It may be due to the fact that participants were recruited with diversity in mind, with a concerted effort to sample ethnic minority groups.  It could be due to a lack of SES diversity--the sample, though ethnically diverse, was mostly middle-class, and the restricted range may have precluded finding an SES effect.  It could also be due to the fact that participants were recruited from an area around three major California universities, where autism awareness is high and participants were likely to receive a diagnosis.  Or, it could stem from the MIND Institute staff's thorough diagnostic evaluation process, which was uniform across participants, regardless of their ethnicity or SES.  One should not expect this lack of ethnic and SES identification bias in the general population.
4 There is one other group that might be worth screening early: those with older siblings with related diagnoses, such as ADHD or specific language impairment (SLI).  However, Ozonoff did not discuss this group, compare their elevated risk of autism diagnosis to that of those with autistic siblings, or recommend more aggressive screening for them.