Tag Archives: Research

Why it matters whether autism is a trait or a unified condition

I’ve written a lot about autism as a trait, contrasting this with a “single unified disorder” narrative.

To me, this is not a nitpick. It matters very much whether we think about autism as a “single disorder” kind of thing, or a “dimensional trait” kind of thing.

Take a popular media article from time.com that came up on Twitter today, about the “Intense World” theory of autism. It’s called “What if people with autism are actually hyperfunctional?” and a sample quote is:

Now, a new study published in the journal Frontiers in Neuroscience suggests that the brains of people with autism are actually hyperfunctional rather than stunted or impaired, and that if treated early in a very predictable environment, symptoms could diminish.

The article goes on to suggest that if autism has this etiology, it should significantly change treatment strategies.

This study is interesting, but it applies to only some autistic people. I don’t think it’s relevant to me or my son, for example.

Results that apply to only some people are still interesting! It isn’t necessary to overhype into a unified theory of autism. But there’s a practical consequence if we only apply a result to a subset of autistics, and that’s the need to figure out which people it applies to.  The autism diagnostic criteria don’t do that work for us.

If we apply a research discovery to the wrong people, then we might harm them by using the wrong approach to helping them.

This particular result, because it’s about being “hyperfunctional,” also continues the disability superpower trope, something that can be harmful by creating feelings such as these. When presenting this kind of “autism as a strength” idea, we have to be sensitive from a human perspective, thinking about autistics who may read about it and think “well, I don’t feel hyperfunctional” or “I don’t seem to have any special skills.” Here’s where always qualifying with the word “some,” some autistic people, can be a small but helpful gesture.

But most importantly — however an article like this one on time.com plays out in practice — it’s inaccurate in a way that deserves correction.

To see this, rewrite it with something we all agree is a dimensional trait, such as intellectual disability, and a single condition that causes that trait, such as Down Syndrome. We might write “What if people with intellectual disability actually have trisomy 21?” and we might talk about how we need to focus on low muscle tone, short stature, and congenital heart disease as central to the treatment of intellectually disabled people.

I think we can all agree that this would be more than oversimplified; it would be incorrect and lead us to flawed treatments. In cases of intellectual disability that are not trisomy 21, we would be badly mistaken to go looking for the characteristics that make up Down Syndrome.

If time.com made this mistake about intellectual disability, they would have to issue a correction. The reason they can mess this up with autism is that autism researchers are also still messing it up, and the mass media follows them. The most cutting-edge researchers are now talking about “the autisms” and so on, but lots of them haven’t caught up.

So whenever some poorly-designed study correlates stuff with autism, and the media reports this as a possible new unified theory of autism, it’s misinformation. Plain and simple. It’s no different from asserting that trisomy 21 is the unified theory of intellectual disability.

There are more known etiologies for intellectual disability than for autism, no doubt. But autism does have some known ones, and there’s no evidence that the remaining idiopathic cases of autism (or intellectual disability) will turn out to be from some unified cause. Most evidence seems to point the other way toward diverse causes.

Discovering trisomy 21 was still a big deal, still very interesting, even though it doesn’t explain all intellectual disability.

When we say “autism is due to intense world,” that’s a much stronger claim than “some autism is due to intense world,” because it requires us to not only prove intense world but also to disprove every one of the other zillion proposed theories of autism. When it comes down to it, quite a few of those theories could be true … for particular autistic people and not for others. To help each person, we need to understand what autism means for them, individually.

Good science and good medicine require us to be precise about our claims and our terminology.

 

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Autism and prediction

Via this post by John Elder Robison I just read a new paper “Autism as a disorder of prediction” (the full text is available but took me a while to find; click on the red Adobe Acrobat icon).

Statistical vs. Logical Prediction

The paper talks about a particular kind of prediction, which they call “Markov chain” (you predict Y after X, if Y is statistically common after X). Markov chains are often used in computer programs to generate nonsense text that matches a “genre.” A Markov gibberish-generator analyzes how words tend to group together in a bunch of sample text, then generates text with those same statistical probabilities. The result is humorous nonsense that sounds like a parody of the genre used to “train” the gibberish-generator.

In the fields of linguistic anthropology and sociolinguistics, these statistical properties of text are thought of as largely-unconscious ways to convey meaning, often social meaning. For example, the way we talk (word choice, pronunciation, gestures, sentence length, etc.) is often enough to let other people place us socially: race, class, gender, even occupation. This social meaning may have nothing to do with the actual “denotational content” (dictionary definition) of what we’re saying; it’s a sort of overlay. And it’s based on statistical probability (stereotype, in essence) rather than logic. The same mechanisms that define a literary genre such as the “romance novel” also define genres of everyday speech and genres of identity.

A famous on-purpose example of Markov genre parody was Alan Sokal’s hoax in the journal Social Text. A famous not-on-purpose example is anything written by Thomas Friedman. These are texts that appear coherent and match a genre, but their logical content (i.e. what the words mean in a dictionary sense) makes no sense.

I’ve also known several people in real life who were like this, very charismatic, sounded very convincing in their social role, successful even, but the words meant very little beyond “I am talking like a CEO” or “I am talking like a minister.” These people were all-genre, no-content. Finally there’s an interesting condition called Williams Syndrome which leads to intellectual disability paired with the ability to convincingly inhabit social roles.

The point here is that the ability to make statistical language chains does appear  to be decoupled in some sense from the ability to think logically.

With that background, let’s get back to the paper.

Problem: Attempted unified account of autism

Let’s note that the paper is on a fool’s errand trying to unify and explain all autism, and these authors should take Lynn Waterhouse’s advice on that front .  The paper would still be interesting if it led to an account of some conditions underlying autism, and that should be our default interpretation of it.

Problem: Assumption that if it correlates with autism, it must be bad

And let’s note that the paper takes whatever thing correlates with autism and assumes it must be a bad thing, which is simply unscientific as usual. Statistical Markov-style prediction creates many of the known cognitive biases, not to mention racism, sexism, and a lot of nonsensical speaking and writing. Unquestionably, this kind of thinking is also necessary for humans to get things done — it isn’t effective to think everything out explicitly all the time — but there’s a reason we have the ability to both “pattern match” and also think things through step-by-step.

Possible meaning and future direction: intellect and instinct again

In the past I listed 20+ word pairs used in everyday language and various academic fields to refer to the distinction between “intellect” and “instinct.” Here’s the post listing those and talking about how I feel it relates to autism.

To me this prediction paper is getting at the same dichotomy again, this time calling “instinct” “Markov prediction.”

Generations of academics from all kinds of fields have wrestled with this distinction. The theoretical framework is weak; what does this distinction really mean? What does it mean biologically? What does it mean in everyday experience? At the same time, there’s a lot of data and previous work that could be learned from. Sociolinguistics and linguistic anthropology have a lot to offer here, among other fields. There’s no need to start from scratch.

Rather than unifying autism, can we unify some of the past work on this intellect vs. instinct dimension of human experience? Can we figure out if this is a real thing or just a folk theory? Can we decide on ways to measure this dimension?

I think there’s interesting work to be done, somewhere in the vicinity of this paper.

Alternative explanations for prediction failure

Before concluding that failure to Markov-predict is due to deficits in prediction ability (due to our unscientific bias against autism), here are two examples of alternative explanations we could also consider.

  1. Attention and interest.  That is, interest in instinctive prediction vs. a preference for other kinds of cognitive activity. For example, I typically feel pretty good (even superior) at pattern matching in areas of intellectual interest. John Elder Robison brings up the example of autistic kids playing a video game they’re really into.
  2. Interference from a “thinking slow” filter. Introspectively, I feel that step-by-step intellectual thinking builds on a “pattern matching” substrate; each “step” is a pattern match, and you learn to apply a sequence of pattern matches to get to a conclusion. The difference between this and a Markov chain is that you aren’t allowed to use “false” pattern matches (stereotypical associations or genre features), you can only use those that make sense on the literal/factual/denotational/logical level. This is an extra level of filtering which may hinder automatic, instinctive pattern matching. Framed this way, the “problem” is that someone is doing more on top of and beyond Markov prediction, rather than that their Markov-predictor is broken.

I don’t know if these are right; the point is, we’d consider them if we didn’t jump straight to “if it’s autism, it’s broken.”

Avoiding fuzzy thinking

This paper is a great example of how our biases (toward autism as a unified condition, and toward autism as an unqualified deficit) can cloud our insights.

If we open our minds to the possibility that we can understand some autism, and to the possibility that some traits may be both strengths and deficits, depending on context, we can explore a lot of ideas that we might otherwise miss.

To find the truth researchers must make things more complicated.

Book: “Rethinking Autism: Variation and Complexity”

More and more researchers, autistics, parents, and professionals are questioning whether DSM categories, and Autism Spectrum Disorder in particular, hold up to scrutiny.

In Rethinking Autism: Variation and Complexity (2013), Lynn Waterhouse undertakes a comprehensive review of autism research to argue against autism as a single, unified disorder.

She argues that while we’ve had no success finding any single cause or unified understanding of autism, we do have plenty of data pointing us to an alternative research agenda focused on heterogeneity.

The book is an argument, not an opinion piece or political manifesto. It presents a pile of research findings, and makes a case for what they tell us.

Dr. Waterhouse goes beyond “the autisms” and argues that autism is not a disorder, or set of disorders. Rather, it’s a trait which may be produced by many different underlying conditions. Calling these conditions “autisms” would be like saying “flu is one of the fevers,” or referring to all fever-causing conditions as “the fevers.” In her words,

Given all the available evidence, however, the least speculative scientific position would not be the creation of autism subgroups or a creation of “the autisms.” The least-speculative and most phenomena-conserving position would be to view autism as two symptoms expressed in association with a wide range of genetic disorders, and a wide range of environmental causes.

She proposes that we diagnose symptoms, rather than a disorder:

The most simple and minimal solution would be to replace the DSM-5 diagnosis with an open set of symptoms that make no claims to be a disorder.

In this approach, we would diagnose “social impairment,” “intellectual disability,” “hyperactivity,” “repetitive behaviors,” “sensory processing difficulty,” and so forth separately. Some people would have both social impairment and repetitive behaviors (what’s now called autism), while others might have only one of the two. And many people might have other traits as well, which are not currently part of the autism criteria.

In fact, Dr. Waterhouse argues that most autistic people have some underlying condition which gives rise to both autistic traits and also other traits which are not part of the ASD criteria. These non-ASD traits are diverse; everything from ADHD to epilepsy to intellectual disability. (And some under-researched areas of strength.)

Why does it matter?

Because there is no unique unifying deficit, and because there is no evidence for causal specificity for autism, there is a clear detriment to maintaining the diagnostic category of autism spectrum disorder. The diagnosis misguides researchers, parents, professionals, and the public into the illusory belief that research will find a unifying deficit that would lead to a “cure” for the autism spectrum. Equally important, this illusion has driven the expenditure of an enormous amount of research effort in a continuing series of failed quests to unify autism.

Rethinking Autism will be too dense for many readers. Though Dr. Waterhouse makes an effort to define jargon (and overall writes clearly), there’s a lot of detail to wade through. The book also has an “academic book” price rather than a “popular book” price.

I don’t mean this as a criticism — we needed a thorough treatment of the topic — but I would love to see the same ideas in a more popularized format as well. For now, if you want a shorter version, you could read this blog post and hope I don’t mangle things too badly! I hope you will read the book yourself for the full argument and accompanying evidence.

This post

I’m sharing my notes after reading the book, starting with a summary of selected points, and continuing on to some of the personal reactions and ideas it left me with.

Indented quotations are from the book unless otherwise specified.

Three Arguments

Dr. Waterhouse summarizes her own book early on, so I’ll start with her summary of its three general arguments:

Argument 1, variation requires explanation:

… autism variation in etiology, brain deficits, behaviors, and life course is real and extensive and carries important information, therefore this variation should be explained rather than accepted, minimized, or ignored.

Argument 2, research must consider the full phenotype:

… diagnostic criteria for autism spectrum disorder have mistakenly excluded frequently-occurring symptoms of the autism phenotype as being outside the autism diagnosis. Intellectual disability, attention deficit/hyperactivity disorder symptoms, motor disorders, epilepsy, and, in DSM-5 developmental language disorder symptoms, have been excluded from the autism diagnostic phenotype. Excluding these symptoms from a diagnosis of autism has not helped us to understand the varied complex autism phenotypes, and has consequently hampered research discovery.

Argument 3, unified theories of autism are harmful:

… there are multiple causes for complex autism phenotypes, and understanding these causes will not be advanced by theories that propose a single unifying cause or feature for autism.

Does autism exist?

Of course the traits and people we currently classify as autistic are real. But perhaps there’s no out-there-in-the-world objective reason to draw a circle in the continuum of reality surrounding precisely those phenomena we currently call “autism.” Alternative circles may have more practical and explanatory power.

Dr. Waterhouse calls the cultural creation of autism reification; “the conversion of a theorized entity into something assumed and believed to be real.” We’ve moved from Kanner’s original 1943 theory of a unitary disorder, to a billion-dollar research agenda correlating stuff with the disorder, without stopping to prove the disorder exists.

In his foreword, Christopher Gillberg worries about misinterpretation of this argument, though he concurs with Dr. Waterhouse:

Having said this, I realize it may sound as though I do not “believe” in autism. To the contrary, I am acutely aware of the reality of autism; my endless flow of patients is convincing in itself. However, the fact is that we do not know what autism “is.” I have been in the field for forty years, and I can honestly say that I do not believe we are any closer now than twenty years ago to a real understanding of what it is about autism that makes experienced clinicians “certain” that it is autism regardless of whether operationalized criteria for the disorder are met or not.

Many routes to social impairment and RRBs

Dr. Waterhouse writes:

The first diagnostic symptom of autism, social interaction impairment, is likely to occur when any of the many brain systems that govern human social behavior are disrupted. These systems include the detection of biological motion, face recognition, emotion recognition, emotion experience and expression, a drive to bond with others, pleasure in human physical contact, ability to communicate, and other component social skills. …

The second autism symptom of restricted and repetitive behaviors and/or sensory abnormalities is likely to result from disruption of a variety of brain systems regulating motor planning, motor symptoms, sensory systems, executive functions, reward circuits, motor repetition, motor inhibition, and other symptom-component skills.

Social interaction involves virtually the entire brain, working in coordinated fashion. Therefore, many specific brain differences, and most general brain differences, could result in social interaction differences. There need not be anything in common amongst those differences — other than “they all affect social interaction.”

Many outcomes from single genetic risk factors

Eliding the book’s lengthy review of genetic risk factors into one conclusion:

Nearly all gene variants and chromosome duplications and deletions found for autism carry risk for other psychiatric and neurological disorders.

This is evidence that the currently-identified disorders do not draw lines in the proper places. We often say that someone has “comorbidities” with autism (such as ADHD or intellectual disability), when (often) it may be more accurate to say that they have a single condition with many effects.

Broad autism phenotype

Dr. Waterhouse reviews the research on “broad autism phenotype,” and concludes that it is as heterogeneous as autism itself:

What is clear from these findings is that researchers have not discovered any consistent pattern of traits for the broader autism phenotype, and that the great heterogeneity found for autism symptoms is true for symptoms of the broader autism phenotype.

Implications for genetic counseling

Many may have read that a family with one autistic child has a 10%-ish (depending on the study) chance of autism in a second child. However, Dr. Waterhouse points out,

All infant sibling studies exploring how likely a family is to have a second child with autism generate a single risk rate. However, that single rate is really the average of many different individual family risk rates.

To think about genetic risk clearly, researchers and prospective parents once again need to dive into heterogeneous detail.

For example, in a family like mine, where three generations (that I know of) all have similar traits, the simplest explanation for autism is that it’s inherited. But plenty of autism in other families appears to be related to prematurity, epilepsy, de novo mutation, and so on. Simple conclusion: in our family, the chance of autism in a second child will be well above average. But another possible conclusion: not all autism is the same, and in our family it has never been accompanied by intellectual disability or epilepsy. So those accompanying traits may be unlikely (or if they appear, they might be from a distinct cause, which could interact with inherited social impairment to create a more complex phenotype).

By understanding autism’s heterogeneity, genetic counselors might give better advice about autism inheritance in a particular family. Giving families the average chance of autism for a second child is misleading.

A research agenda around heterogeneity

Dr. Waterhouse writes:

Abandoning the diagnosis of autism as a disorder would free researchers to recognize and study the complete phenotype of children expressing neurodevelopmental social impairment.

Recognizing that many conditions cause autism, that most risk factors for autism also cause differences other than autism, and that individuals may have multiple conditions, might make research far more complicated than “correlate xyz with autism.” But it might also make research more meaningful and realistic.

Dr. Waterhouse argues that continued research around unifying features of autism requires progress on synthesis, but that “the hundreds of theories proposing a unifying feature for autism would not require synthesis if autism were no longer viewed as a single disorder.” She cites P.E. Meehl’s theory of “ad hockery” and argues that researchers have been inventing and rejecting a series of weakly-supported theories, rather than reconceptualizing the big picture.

Autism and gender

Rethinking Autism devotes some space to autism’s greater prevalence among males.

In the book’s argument, the male/female ratio will be a composite: an average made up of many “distinct male to female ratios each of which is determined by a specific causal risk etiology and consequent mediation of brain development.”

An interesting point, which I was not aware of, is that neurodevelopmental disorders in general are more common in boys. When born preterm, for example, boys are more likely to die, suffer complications, or have long-term disabilities.

Since infant boys appear to be more fragile than infant girls, explaining this general difference may go a long way toward explaining the difference in autism diagnosis.

(Side note from me: underdiagnosis in women due to gender bias may be reduced if we can replace “know it when I see it” diagnosis with better scientific understanding.)

Some personal reactions

I’ll switch here from summarizing the book to some of the thoughts I had after reading it. I don’t claim to be an autism expert. I’m just some guy trying to figure out what all this autism noise means to me and my family. Caveat emptor.

Many of my notes are speculative or would require a whole new book to discuss, so I don’t mean to criticize Dr. Waterhouse for leaving stuff out.

I also don’t want to imply that Dr. Waterhouse does (or does not) agree with any of my political or social opinions — I have no idea. Her book tends to stick to factual matters.

Enough defensive disclaimers… you get it.

The practical impact of autism’s reification

For the most part, Rethinking Autism argues against a unitary disorder on scientific grounds (that is, it’s slowing scientific progress).

Much more could be said about the effects of the “autism” concept on our day-to-day habits of thought, and this is why I hope to see Dr. Waterhouse’s argument reach a wider audience.

Often, people have a straightforward idea about autism: they think of it as a single disease, analogous to the flu, which “breaks” the brain. This leads us astray in so many ways. Spend some time reading autism blogs, comments, or a site such as MyAutismTeam, and you’ll find all sorts of faulty reasoning.

Just some of the mistakes people make (in my opinion; Rethinking Autism doesn’t tackle all of them):

  • that it’s a single condition rather than a trait or symptom (with many causes)
  • that there’s a radical break or categorical difference between “normal” (neurotypical) and “other” (autistic) (reality: some underlying conditions might be normally distributed, while others might be bimodal?)
  • that the condition resulting in autistic traits is unequivocally “bad” rather than a tradeoff or mixed blessing
  • that a treatment could be found which would apply to all people with autistic traits
  • that the cure is “medical” in nature (drugs, diet, etc.), rather than educational in nature (perhaps this varies across underlying conditions too?)
  • that whatever condition an autistic person has results in exactly the two traits mentioned in the autism criteria (social impairment, restricted/repetitive behavior) and no others
  • that each paper or presentation or book about autism applies to all people with autism
  • that their loved one will be miserable (because autism sounds so scary) or a genius (because hey, Bill Gates and Mozart have autism too)
  • that autism can be separated from a person
  • that some of a person’s behaviors are “because of autism,” while others are not, and this should affect our response to those behaviors

Rethinking Autism doesn’t address all of these directly, but its discussion of the “unitary disorder” problem does challenge our assumptions in a helpful way.

Bad analogies lead to bad conclusions, with very real practical consequences.

I’m aware that people will be wrong on the Internet no matter what. But perhaps we’re presenting “autism” in a way that starts even thoughtful people off on the wrong foot. What if we understood autism a bit more like dyslexia or introversion, and a bit less like the flu?

Dr. Waterhouse’s catalog of evidence against the “unitary disorder” model does us all an enormous service by sending us down a path that might get closer to the truth.

Advocacy benefits of a unitary autism

“Autism” as a concept has been politically and socially successful.

Grouping many neurodevelopmental differences together makes them into a big deal, rather than a collection of isolated cases.

We have an emerging Autistic identity made up of people diagnosed with autism.

We’ve been successful in raising funds for autism research. Imagine lobbying and advocacy in the name of “a wide variety of neurodevelopmental differences which create social challenges” — not the easiest marketing task. “Autism” is much catchier.

Very real material benefits are tied to the autism label. Insurance companies in many states are now required to cover autism, but they may not be required to cover developmental delays or differences which are not labeled autism. Similarly, school district services or other government services may be tied to autism diagnosis. Anti-discrimination and accommodation rights kick in with a diagnosed “disability,” which may be unavailable to those whose disability hasn’t been reified.

It will be a long, hard road to change the way we talk about autism (and neurological difference in general) without giving up needed services and accommodations.

One positive outcome, however, could be to expand services and accommodations to those who need them but who don’t quite fit the current idea of “autism.”

It may be a hard road to help every person on a “needs help” basis rather than a “has a disorder” basis. But it could be worth it if we make it to the end.

What should professionals tell those in their care?

Current science appears to be out of sync with current professional practice. The nature of diagnosis may inflict unnecessary stress on autistics and loved ones — diagnosis is an elaborate process ending in a dramatic (and often traumatic) revelation about Autism or Not Autism.

In a cold scientific sense, “your child would benefit from social skills tutoring,” and “your child has autism” can mean about the same thing for many children. But these framings certainly do not have the same impact on parents. A traits-based approach could be much less frightening than a disorder-based one.

With “autism” written into laws, insurance paperwork, school rules, nonprofit charters, books, and every other institutional resource, how can anyone involved with autism be honest about what we know? A diagnosing clinician can’t set aside two hours to tell flustered parents, “look, here’s the complicated truth on the one hand, and here’s the charade (involving an imaginary disorder) you’ll have to participate in on the other hand.”

But misinformation has consequences, as any cursory participation in a support group or online autism forum will reveal.

In my experience, professionals avoid “autism politics” like the plague (understandably); but this leaves their patients unguided and vulnerable to quackery.

People assume that because autism shows up as a diagnostic code in the same spot a doctor would write “flu,” it must be the same category of thing as “flu,” then they reason by analogy. Clinicians might ideally find a way to say “this is a diagnosis but not that kind of diagnosis.”

Stigma, overreaction, quack treatments, and so on are among the downsides of autism diagnosis. If these problems could be solved, there may well be even more kids who would benefit from some social skills tutoring or behavior analysis, beyond those who meet the autism threshold today. It should not have to be a big deal to get appropriate, individualized education.

Defining social impairment, RRBs, SPD

Dr. Waterhouse questions the unitary nature of autism and suggests breaking apart social impairment and RRBs as distinct traits. While this would be progress, I suspect there’s another possible book exploring the traits themselves. For example:

  • What are the best ways to measure these traits? Can we do so dimensionally rather than categorically? Can we measure them across the population and not only in the “disordered” population?
  • How can the traits of social impairment, RRBs, and atypical sensory processing be further decomposed into more specific traits? All of them are quite broad in themselves, and may have the same reification problem that autism has.
  • Many of the conditions which generate social impairment or RRBs may be normally rather than bimodally distributed; when is this is the case? When it is, how do we validate the line drawn between diagnosis and “normality”?
  • When we measure these traits are we trying to measure “functional impact” (effect on quality of life) or are we trying to measure an innate, lifelong feature?

I find that this last point, in particular, creates muddled thinking in the real world across stakeholders and contexts.

Are autistic traits contextual functional difficulties or lifelong differences?

Say you are creating a measure of autism (or its component traits) — a checklist or questionnaire of some kind. Some questions would tend to be relatively stable (less likely to change across multiple administrations to the same individual, even as the individual’s skills improve). Some other questions would tend to be relatively correlated with measures of quality of life or independent living and would improve in response to education and practice. These may not be the same questions. Which ones do you keep? Which are the ideal measures of social impairment or RRBs?

Put another way, if an autistic person, through hard work, learns adequate social skills, are we going to say:

  • they are still an autistic person but one who has compensated for social weaknesses through time and hard work;
  • they were misdiagnosed and never had autism, because autism means that they can’t ever learn social skills; or
  • they had autism but through hard work have now been cured?

In current usage, the word “autism” means “fixed trait” sometimes and “current functional impairment” other times, which creates confusion.

When autism diagnosis operates as a medical/educational “certificate of need for services,” it should reflect degree of practical impairment. But scientifically, we might want to understand autistic traits through factor analysis. That means controlling for other factors such as personality and intelligence and education. The “same amount” of autism, in some theoretical sense, would be more impairing given fewer other compensating strengths.

At one point Dr. Waterhouse quotes P. Szatmari on this point:

social communication and repetitive behaviors may not be the most useful for categorizing children with autistic spectrum disorder … because variation in these dimensions seems to be only weakly associated with variation in outcome and response to treatment, which are more closely related to cognitive and language abilities.

Inserting my own editorial here, I think this points to a need to separate the “medical/educational certificate of need” for someone with autistic traits, from the scientific measurement of said traits in isolation. Not that this would be easy in practice.

Dr. Waterhouse talks about this somewhat by identifying “stakeholder conflict over the control of diagnostic criteria” as one of three “pressing problems for the diagnosis of autism.” One solution to this stakeholder conflict might be to invent different systems of classification for different purposes.

I believe it’s already true in the United States that schools and social security make their own determinations, which aren’t necessarily the same as the medical diagnosis.

Will we find evidence for “not like my child”?

Internet autism fights include the well-known “not like my child” trope, in which parents assert a bright line in the autism spectrum between noncommunicative autistics and autistics able to participate in Internet flamewars.

If we break apart autism spectrum disorder, it is possible that some underlying conditions are general brain disruptions which are always and absolutely disabling; while other underlying conditions are closer to a mixed blessing with strengths and weaknesses. There may also be conditions which are ambiguous, with their value in the eye of the beholder, or with a variable outcome. And of course there will be people with multiple conditions.

This adds complexity to the “not like my child” debate: it means that there may someday be many scientifically-validated lines between the conditions we now label “autism.” Such lines could be used for good or for evil.

Conditions deemed “severe” could see renewed stigma and dehumanization. Conditions deemed less severe could see loss of services and loss of legal protections.

On the positive side, more realistic understanding could lead to more appropriate services and treatments.

As we learn more, the cultural positioning of the facts will have a lot to do with their practical effects.

Savant and special skills, and autistic strengths

To date, attention to autistic strengths has often focused on savantism and “splinter skills.” Dr. Waterhouse devotes a chapter to this topic, with the conclusion that research to date has been inadequate:

In fact, measured intelligence varies widely in autism, and the possible casual web of associations between intelligence, savant skills, superior perceptual recognition and discrimination, and sensory abnormalities has not been determined.

Dr. Waterhouse describes the autistic savant as an “unhelpful stereotype,” and it’s hard to disagree. The terms “splinter” and “savant” seem very problematic to me.

However, I believe there are many better research directions related to strengths.

How do variations in personality and intelligence relate to social impairment? Are there tradeoffs or “tunable factors” in the structure and function of the brain, where evolution and development may optimize it for some tasks at the expense of others? Are there context-dependent traits which are strengths in one context and weaknesses in another? How could schools, in particular, be more or less friendly to particular traits, and can we better adapt them to diverse students?

An occasional paper has interesting leads relating to strengths, for example in “Children with autism do not overimitate” autistic kids copied adult actions in a more cognitively-demanding way than typical kids. Autistics determined the purpose of the task and filtered out useless steps, rather than copying everything without question.

Anecdotal strengths of autistics include hard-to-quantify personality traits such as honesty, straightforwardness, independent thinking, and persistence. I believe there would be value in somehow quantifying or characterizing these stereotypes. Do autism interventions affect these qualities?

Finding ways to talk about autistics (and diversity in general) in a positive way may be one of the more powerful “treatments” we could discover.

As a 2-year-old reader myself, and dad to another 2-year-old reader, I can relate firsthand to hyperlexia, one of the skills Dr. Waterhouse mentions. Darold Treffert’s “Hyperlexia III” paper helpfully explores the heterogeneity of hyperlexia through case study impressions (though Dr. Treffert’s paper is more confident about the meaning of “autism” than I’m comfortable with).

To me it’s a mistake to start from the view that hyperlexia is a “splinter” skill, because it may instead be a manifestation of a more general interest, preference, or ability. One professional has used the term “splinter skill” talking about my son’s reading; I felt this was inappropriate and unhelpful.

Autistic strengths deserve exploration, as do strengths in the general population. How can we understand variations in intelligence or social skills in autistics, without understanding these variations for everyone? Better understanding of intelligence in general means better understanding of how low or high intelligence might interact with autistic traits.

Strengths are a key part of anyone’s phenotype and are part of the data a better theory of autistic traits will have to explain. The full scientific picture must include harmless and beneficial “symptoms” too, not only troublesome ones.

Skills are also an important element of each individual person’s human experience. Even severely-disabled persons have skills. No one can be adequately described using only the language of disorder.

To help an autistic person we need to know what strengths they might build upon to become their best selves. Responsiveness to various interventions, for example, might hinge more upon which strengths are present, than upon which weaknesses are present.

Autism may or may not be shown to include skills, focuses, or ways of thinking which other kinds of minds emphasize less. But whether or not autism involves “special” skills, strengths will vary across autistics, just as they do across non-autistics.

If current research has been limited to “savant” and “splinter” skills then we must get past that research and do better. If there is better research already, I wish it had been included in Rethinking Autism.

Language neutrality

While it’s reflective of the research she’s reviewing, and a medical perspective, I believe Dr. Waterhouse’s book could be improved by more neutral language.

As I argued in a previous post, the value-laden language of disease puts us in a less-than-objective frame of mind. We should all make an effort to use neutral language (“traits” not “symptoms”, “differences” not “abnormalities”), and to mention strengths when applicable.

Four small concrete changes which could add balance to the book:

  • use of more neutral terms where appropriate
  • when enumerating potential components of autistic phenotypes, be careful to include traits which are not currently in the DSM, including positive traits
  • when discussing research toward a cure, also discuss research toward accommodation
  • more exploration of possible heterogeneity-aware research agendas around strengths and skills

I do not mean that autistic traits should be whitewashed or made to sound all roses and lollipops, only that strengths and skills (and variation in those) are part of the complete picture.

For now, we often (usually?) can’t prove whether a given autism-correlated brain difference is even related to practical impairments, let alone how it’s related. Think about someone with bulked-up arms because they use a wheelchair; autism research often does the equivalent of assuming that the large arms keep this person from walking. An autism researcher might identify “excess arm muscle” as an “abnormality.” While perhaps true in some literal sense, in practice we use the word “abnormal” to mean “thing which needs fixing,” so this usage is incorrect. Morton Ann Gernsbacher has a great list of examples in real papers.

Our language habits should reflect our ignorance, to help keep our thinking on the right track.

Research starting from case studies

It may be valuable to mine anecdotal experiences of autism for clues leading to quantitative research ideas. There are many different introspective accounts:

  • Temple Grandin’s “thinking in pictures”
  • The “motor apraxia” or “locked in” description given by many nonverbal autistics, such as the boy in “The Reason I Jump”
  • The “overly intellectual” experience as first suggested by Hans Asperger
  • The “sensory overload” experience described by many
  • The commonalities in accounts of hyperlexia

The challenge is to map these experiences to measurable and thus researchable phenomena.

Developmental perspective, feedback loops, and neuroplasticity

Following the studies she relies upon, Dr. Waterhouse argues against autism as a unitary phenomenon using primarily snapshot-in-time data. But there’s also evidence of heterogeneity from a developmental perspective, that is, single individuals with changing traits, skills, and neurology over time. Future research could expand on this.

She does say that:

Advances in the understanding of causes for complex autism phenotypes will also depend on the increased knowledge of environmental impacts on brain development, and increased knowledge of the mechanisms of the dynamic processes involved in brain development.

Dr. Waterhouse found a few studies in this area, such as C. Fountain et al on “Six developmental trajectories characterize children with autism.”

I am hungry for more research here.

The unitary account of autism fails to explain optimal outcome, for example. In case studies of so-called Einstein syndrome or hyperlexia III, autistic traits in early childhood do not result in serious lifelong impairment (though the jury is out on whether they result in lifelong difference).

In studies of interventions such as ABA, there have been “responders” and “non-responders”; how did these individuals differ? There’s again some research, but not enough to reliably predict in advance who will respond.

Effective education for autistics tends to be intensive (20+ hours per week) and consist of repeated practice in areas of weakness. We know that this practice gets results. How does this affect what shows up on a brain scan?

When research correlates brain activation or other physical neurological features with autism, there’s rarely an attempt to look at how those features change over time, and how they might relate to practicing skills. Feedback loops may amplify some small feature present at birth into a much more significant difference.

An understanding of autism heterogeneity must include an understanding of change over time.

We would do well to remember that, as Gabrielle Giffords illustrates, the human brain has an amazing ability to adapt and change. Even a bullet in the head may not be as permanently impairing as we intuitively expect. The intensive therapy for Representative Giffords was about the same as that for someone with inborn brain differences: speech, physical, and occupational therapy. Education and practice, in other words.

The brain exists to learn; learning means physical, neurological change. Change could well be viewed as the purpose of the brain. One consequence of autism’s reification may be an underemphasis on change.

On education

At one point Dr. Waterhouse laments that

In fact, the only treatment for autism at present is intense and focused education programs.

She expresses hope for the development of drug therapies, once the conditions underlying autistic traits are unpacked.

Education is inadequate for many autistics, but eliminates the downsides of autistic traits entirely for others.

We might have to be cautious about locating dysfunction in individual children, in those cases where it should be located in educational bureaucracies. The literature of homeschooling and alternative schooling describes at length the ways in which typical schools do not have to be the way they are. Some milder manifestations of autism, ADHD, anxiety, and other traits appear to amount to “school disorder,” reflecting many schools’ inability to provide appropriate education to atypical children.

ADHD does have medication options, which appear to have gone a little bit off the rails.

I’m not categorically against medication, but ADHD may be a cautionary tale where it’s been overused for the convenience of adults.

We should also keep in mind that intensive education remains underused as an autism intervention. Many autistics do not have access. In our area, there are countless kids who need not have a significant long-term disability, but who nonetheless will struggle mightily because their “treatment” consists of an hour per week of sensory gym or social stories. We continue to lie to parents (if only by omission) and leave them with the impression that an hour or two per week of social enrichment may be sufficient.

While researching medication, we could also be saying more loudly that we do already know ways to help, we just don’t always care to pay for them.

Education is less stigmatizing and not inherently medicalized. It sends a message of help (teaching skills) rather than a message of change (removing traits).

Subjectively, my wife and I think of our son’s autism as analogous to dyslexia; he thinks in a certain way that’s friendly to some skills and unfriendly to others. As with dyslexia, education feels like a proper response.

Of course one takeaway from Rethinking Autism could be that not all conditions lumped into “autism” today should be thought of in the same way. We know that some people diagnosed with autism are not responsive to education, or at least not responsive to the kind of education offered.

I don’t expect Dr. Waterhouse would disagree about the value of appropriate education, and it would be great to have medication available as an option. I just worry about its misuse. I don’t know the answer.

Reification of conditions besides autism

A similar “reification” critique likely applies to other DSM disorders, as Dr. Waterhouse occasionally hints. A similar book could potentially be written about ADHD, for example.

While I haven’t read much academic research about giftedness, many parents and popularizers claim that giftedness isn’t just higher IQ, but a categorical difference. In fact, they’ll often describe qualitative differences which overlap autism: social distance from peers, intense focus, and sensory issues.

More than one parent (that I’ve seen) has turned up in an Internet forum rejecting an autism diagnosis on the grounds that “really” their child is gifted, as if autism and giftedness were known to be mutually exclusive. These parents implicitly believe that there are two unitary phenomena “autism” and “giftedness,” each of which produce similar observable traits, but which are distinguished by some as-yet-unknown underlying “what’s really going on.” Professionals do this too; see “That’s not autism, it’s simply a brainy, introverted boy”, for example (my previous criticism of that article).

Perhaps there’s research supporting criteria other than “I know it when I see it” for this distinction? Who knows.

Conclusion

I’m grateful for Lynn Waterhouse’s book and fervently hope it will help knock autism research out of a rut (not to mention help improve everyday thinking about autism).

My “crash course in autism” as a new parent included a research review textbook, Autism Spectrum Disorders (edited by David Amaral). I was struck by how little scientists know. And I was struck by how impractical the research was; reading through it, I felt that:

  • only some fraction of the knowledge applied to my son
  • the researchers mostly hadn’t figured out who their findings applied to

As currently used, the word “autism” has very little to say about any particular autistic person — and as a result, neither does the research. This is a disservice to everyone with neurodevelopmental differences, and their loved ones.

Rethinking Autism moves the conversation forward and I hope it will change our thinking for the better.

Unscientific words in scientific papers

It’s common for researchers to compare an “autism group” with a “control group,” on some dimension. Perhaps some part of the brain differs in size or in activation, or the neural network graph has a different shape, or kids with autism have more allergies, or they are less prone to certain cognitive biases, or whatever, the list is a mile long. Then we get a “such-and-such correlates with autism” discovery.

In writing up their research, scientists get out their mental thesaurus and try to avoid saying “more-connected neural network” and “less-connected neural network” over and over. They might start to say things like “connectivity deficit” or “excess connectivity” or “abnormal neural network” or “pathological neural network” or “defective gene.” If the autism group has more then it’s “excess” and if it has less it’s “deficit.”

This is bad science.

Think about what you’d have to prove to justify the words “excess” and “deficiency.” You would need to determine the “best” genotype or phenotype. Then you would need to know thresholds (how far someone can be from “best” before it’s a practical problem). When was the last time an autism study showed either of these?

Just because we demonstrate that something is correlated with autism, we haven’t demonstrated that it is “bad.” We haven’t shown that it results in the negative aspects of autism. We haven’t demonstrated that it’s unequivocally bad; perhaps it’s a mixed blessing. Or perhaps it’s something innocuous and irrelevant (it could share a cause with some forms of autism, but have no functional effect). Or perhaps it’s an effect of autism, rather than a cause.

In most correlation studies, there’s no evidence whatsoever about how or why the thing in question relates to autism, there’s just an unexplained correlation.

Many biology textbooks discuss sickle-cell disease, a genetic trait which can be an advantage: in heterozygous form, it confers resistance to malaria. In tropical regions, evolution tends to select for this gene, even though it has major downsides.

The various conditions which involve autistic traits are undoubtedly more genetically complex. If we are humble and scientific, we might assume that many traits which correlate with autism exist in our genetic heritage for a reason. Since we don’t know what the conditions are, what the endophenotypes are, or how it all relates to observed autistic traits, we need to reserve judgment on whether anything we observe constitutes a “deficit” or “excess.” Stick to saying it’s a difference.

Even when a trait is plainly a deficit in one context, it may be a strength in another. Is sickle-cell disease a net negative? — well, do you live in a malaria-infested region or not?

In my speculative theory about how autism works in our family, it’s easy to see how causes which contribute to “intellect” and causes which contribute to “instinct” would need to be in balance. A person too lopsided in either direction will have trouble. None of the genes or other causes which push the balance one way or the other would be “abnormal” or “deficits” in themselves; only an imbalance or preponderance — potentially in either direction — would cause a problem.

I’m not saying this is how our particular autism condition works, or how any condition works. It’s pure speculation. But the point isn’t that I’m right about this, it’s simply that in many possible scenarios, we don’t know whether the phenomena we’re observing are net positive, net negative, context-dependent, irrelevant, or what.

Outside of autism, think about intelligence. Why are human IQs distributed as they are? Well, some people say that IQ at the very upper limits of the distribution can be a liability. Anecdotally, people with IQs of 150 or 160 may be barely functional. So perhaps intelligence, also, requires a balance. Perhaps we need some genes to make us smart enough, and some other genes that keep us from being too smart. In this balance, there may be many genes which are neither categorically “good” nor categorically “bad.”

Scientific papers should strive to use neutral language, reserving judgment on the merits of the observed phenomena, unless there’s actual evidence about those merits. This goes double for poorly-understood genetic and neurological features.

No “deficits” and “abnormalities” and “dysfunctions,” just the facts.

This should be done to promote sharper, clearer, more precise, more accurate research.

There are ethical implications as well (we should be concerned about stigma and eugenics). But even if one doesn’t care about ethical considerations, factual considerations ought to rule out language based on unproven assumptions about the “best” genotype or phenotype.

(To be clear, I’m not talking about an observable problem described as such; “difficulty conducting a conversation” can be described as a “pragmatic deficit” and that’s fine. The problem comes when we have some proposed underlying genetic or neurological feature, but no proof of that feature’s specific effect on observable behaviors or quality of life.)

Let’s make autism research more useful

Every day there’s a “something correlates with autism” story; Emily Willingham just did a roundup of weird ones. When I first started to learn about autism, it took no time to realize that these aren’t very helpful. I wish researchers would focus elsewhere, and some already are.

Here are two studies (these happened to pop up today) that did better:

I didn’t dig in on these studies in detail, the point is that their reported findings are much more informative than they would be if they were simply “autism correlated with motor skill impairments” or “autism correlated with de novo mutations.” They go a level deeper and attempt to look at dimensions within autism.

Here’s what’s wrong with a “correlate autism with X” study.

Plenty of evidence seems to support the idea that autism is more like a trait or symptom than a disease. Some people seem to experience autism primarily as sensory differences; others as a different kind of thinking (perhaps in pictures, or in explicit, intellectualized fashion); others emphasize medical issues such as seizures or tuberous sclerosis with autism as an effect. Sometimes autism comes with intellectual disability, other times it doesn’t. It may or may not imply motor deficits. On and on — there are so many differences. We’ve put all kinds of people and experiences together and said: these people have a brain focused on something besides social interaction, and that’s what’s most important about them.

We need to view this grouping as contingent and pragmatic, to be used when it makes sense. If we’re asking, “should we be concerned about this person’s ability to make friends and navigate social situations in daily life?” then the broad “autism” label is appropriate, because it’s defined by something close to that question.

But if we’re asking, “what specific education or accommodation does this person need?” or “what strengths might this person have to build on?” or “do we expect problems other than the core social deficits?” or “what causes autism?” … any practical question, really … we need more specific ways to group and understand people. Just “autism” tells us little, and may even be actively misleading.

“Autism” has a crude yes-or-no quality. If someone is just outside the autism range on the usual autism assessments, are their social skills perfect or might they benefit from extra help in those areas?

What could researchers do to improve?

  1. Measure autism dimensionally … continuing those measures outside the official spectrum. See if the variable you’re looking at also relates to more-autism-like but not-quite-diagnosable “neurotypicals,” for example.
  2. Measure separate aspects of autism separately. Some research suggests that sensory issues and social issues may not be strongly related, for example.
  3. Look for relationships among those variables which aren’t part of the autism diagnosis, but crop up often in autistic persons. Motor skills differences; language differences; picture-thinkers and word-fact thinkers; attention-seeking behavior; verbal vs. non-verbal; presence of medical issues such as seizures.
  4. Some studies have tried to find commonality in “responders” and “non-responders” to intervention; those are great studies! Which people benefit from which kinds of help?

“Autism correlates with X” research really falls over when it comes to debates about the DSM criteria. How are we supposed to improve the criteria by finding things that correlate with the current criteria? Circular and nonsensical.

In the end, a yes-or-no on autism isn’t enough.  We need to describe a person more specifically, including their strengths, and then list social deficits or repetitive behaviors as one aspect of whatever’s going on with that person. Once we understand autism, it probably goes away as a diagnosis and returns as a trait (one associated with certain diseases, perhaps, but perhaps also arising from certain strengths).

There’s plenty of anecdata out there about kinds of people with autism; picture-thinkers, “little professors,” memorization-loving hyperlexics, lovers of sensory experience. It’s time to try understanding these differences in earnest.

Take the study I linked to earlier, reporting that de novo mutations only correlate with autism with intellectual disability? If that turns out to be true, does it mean that some autisms with and without intellectual disability have distinct causes? It’s a fascinating clue.