A team of NIH-funded researchers at Stanford University Medical
School has found that children with autism improved measurably on a test
of socialization and learning when their therapy included an at-home
intervention with Google Glass. Google Glass is a headset worn like
eyeglasses that provides augmented reality on a miniature screen, with
sound. The smart system of eye wear and mobile-phone-based games helped
the children with autism understand emotions conveyed in facial
Autism is a complex neurological and developmental
spectrum disorder that affects how children interact with others,
communicate, and learn. Many children affected by autism spectrum
disorder (ASD) are unable to discern facial expressions, so miss out on
important cues that aid in learning and socialization.
Stanford team, led by Dennis P. Wall, Ph.D., associate professor of
Pediatrics, Psychiatry and Biomedical Data Sciences, used Google Glass’s
built-in camera along with software customized to run on a smart phone
as an intervention that care givers used with their children at home to
supplement clinic-based therapy. The study was published March 25,
2019, in JAMA Pediatrics.
“Technology can be a terrific
asset to the therapy process, for both physical and neurodevelopmental
gains,” said Tiffani Lash, Ph.D., director of the NIBIB programs in
Connected Health (mHealth and Telehealth), and Point-of-Care Technologies. “This is a heartwarming achievement and a promising example using a bioengineering approach.
The innovative software and hardware solution coupled with the
therapeutic component meets a dire need for many children and their
Google Glass is lens-less, non-invasive, and
peripheral—sitting off to the right side of view for the child. “The
system acts as a true augmentation to their reality, keeping them in
their natural social world, as opposed to taking them out of it,” Wall
said. “In contrast to virtual or mixed reality, augmented reality is
potentially a powerful vehicle through which we can teach children
social skills to rescue some of these deficits early in their
A camera in the device captures the facial
expression of family members in the glasses’ field of view, reinforcing
what the child sees by providing an image and audio prompt. It detects
up to eight emotions: happy, sad, angry, scared, surprised, disgusted,
“meh,” and neutral. The glasses are wirelessly connected to a smartphone
device that may be operated in three different play modes. There is
‘find the smile’ game, where the child is prompted to say something that
prompts an expression in the family member’s face; the ‘guess the
emotion’ game, where the family member asks the child to guess the
emotion from the family member’s face; and free play, an unstructured
mode of identifying facial expressions.
The device also records a
video that parents can observe at a later time to monitor the progress
that their child makes with the activities. “Our hope was that the video
playback would be a good source of reinforcement learning with the
children,” Wall said. “It provides the opportunity for the learner to
focus in on certain human emotions that they may or may not be getting
right, so they might become more adept at detecting those emotions in
The researchers recruited 71 children between the ages
of six and 12 who all had been enrolled in a program of applied
behavioral analysis therapy—the standard care for most children with
ASD. Experts recommend 20 hours per week of the standard therapy, in
which the child interacts with a therapist who leads learning activities
to improve social, motor, and verbal behaviors, as well as reasoning
skills through observation and positive reinforcement. The authors cite
the current cost for this standard therapy to be between $40,000 and
$60,000 per year, noting that parents can often wait up to 18 months for
their child to gain access to the therapy.
Experts suggest that
it is important for children with ASD to receive a diagnosis early—which
can be assessed by the age of two—so that children can begin treatment
as early as possible. According to the authors, learning aids such as
the type tested in the study could begin to address this difficult
challenge of accessing therapy more immediately, outside the clinic.
the 71 enrolled in the study, 40 children also received the augmented
reality device to play the programmed games or freely play during
20-minutes sessions, four times per week. After six weeks, the team
assessed all 71 children on a standard socialization scale.
researchers found that children receiving the smart-glasses intervention
along with standard therapy scored significantly better in the
post-study assessment than those in the control group. Children who used
the smart glasses improved 4.58 points on the standard scale above
those who did not use the Google Glass intervention. Authors unrelated
to the work by Wall and colleagues recently published in Autism Research
that changes of 2 to 3.75 points on the scale represent a clinically
“This is based on a statistically rigorous
approach to the analysis of the data,” Wall said. “We should be excited
about the result. While the overall effect is modest, the positive
change seen in the treated children is significant and points to a new
direction that could help more children get the care they need, when
they need it.”
Wall noted that the device represents a short-term
learning aid and predicts that in the not-too-distant-future there will
be a wider array of available augmented reality wearables. “After a
period of time, they take the glasses off and they grow on their own
into more complex social scenarios.”
Though a playful
intervention, families in the treatment group missed a portion of the
prescribed hours in which to practice with Google Glass, and most
preferred the structured games over the unstructured free-play option.
But the activity was positively received to the point that children who
participated in the study created a new name for the tool, calling it
Superpower Glass, a moniker the authors adopted in writing their report
on the study. The researchers have begun to plan for a larger, follow up
How can we get tangible benefit from the millions we spend on autism science?.
Posted Nov 12, 2017
The U.S. government is the world’s biggest funder of autism research. For the past decade I have had the honor of advising various agencies and committees on how that money should be spent. As an adult with autism, sometimes I’ve been pleased at our government’s choices. Other times I’ve been disappointed. Every now and then I turn to reflect: What have we gotten for our investment? Autistic people and their parents agree on this: The hundreds of millions we’ve spent on autism research every year has provided precious little benefit to families and individuals living with autism today. Over the past decade the expenditures have run into the billions, yet our quality of life has hardly changed at all. It would be one thing if massive help was just around the corner, but it’s not. There are no breakthrough medicines or treatments in the pipeline. Autistic people still suffer from GI pain, epilepsy, anxiety, depression, and a host of other issues at the same rates we did before any of this research was funded. I don’t mean to suggest that nothing has been accomplished. Scientists have learned a lot. They know more about the biological underpinnings of autism. Researchers have found hundreds of genetic variations that are implicated in autism. We’ve quantified how autistic people are different with thousands of studies of eye gaze, body movement, and more. Scientists are rightly proud of many of their discoveries, which do advance medical and scientific knowledge. What they don’t do is make our lives better today. Why is that? In the past I’ve written about the idea that taxpayer-funded research should be refocused on delivering benefit to autistic people. What I have not written about, is why that hasn’t happened, at the most fundamental level. The answer is simple: Until quite recently, autistic people were not asked what we needed. There are many reasons for that. Autism was first observed in children and no one expects children to have adult insight and self-reflection. When autism was recognized in adults, they were assumed to be too cognitively impaired to participate in conversations about their condition. Finally, in the spirit of the times, doctors often assumed that they knew best. They were the trained professionals, and we were the patients (or the inmates.) So doctors studied every question they could imagine, and then some, seldom seeking our opinions except in answer to their research questions. They assumed they knew what “normal” was, and we weren’t it. Countless million$ went down the rabbit hole of causation studies, whether in genetics, vaccines, or other environmental factors. Don’t get me wrong—the knowledge we’ve gotten is valuable for science. It just did not help me, or any autistic person I know. Millions more have been spent observing us and detailing exactly the ways in which we are abnormal. Only recently have some scientists began to consider a different idea: Perhaps “normal” is different for autistic people, and we are it. Again the studies enhanced the scientists’ knowledge but didn’t do much to help us autistics. Then there are the educators and psychologists. They observed our “deviations” and then considered therapy to normalize us. That led to ABA and a host of other therapies. Some of those have indeed been beneficial, but the money spent on beneficial therapy is just a drop in the bucket when considering what we taxpayers have funded overall. Want a different and better outcome? Ask actual autistic people.
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We can tell you what our problems are, in many cases very eloquently. I’m not going to re-state all our needs here. I’ll tell you this: Whenever this topic comes up at IACC (the Federal committee that produces the strategic plan for autism for the U.S. government), the priorities of autistic people seem rather different from those of the researchers our government has been funding for so long. Autistic people have many disparate needs, but they all boil down to one thing: We have major challenges living in American society. Medical problems, communication challenges, learning difficulties, relationship issues, and chronic unemployment are all big deals for us. The issues are well laid out and many. Before autistic people began speaking out in great numbers, all we had was parent advocacy. We should not dismiss that, and parents still have a role today, particularly in advocacy for small children and children who are older but unable to effectively advocate for themselves. Even as we thank parents for their service, it’s time to recognize autistic voices (some of which belong to parents too) should be taking the lead. As much as parents did for us, they also unwittingly contributed to harm. Parents misinterpreted harmless stimming, and encouraged therapists to suppress it, leaving us scarred in adulthood. Many autistics of my generation remember being placed into programs for troubled children with parental encouragement in hopes we’d become “more normal.” We didn’t. Parents have given us bleach enemas, and some of us have died from misguided chelation and other treatments to “cure” our autism. I don’t blame parents for any of that. They did their best, given the knowledge of the day. But it’s a different day now. The children who grew up being “normalized” can talk about how it affected them, and parents and clinicians of today would be wise to listen.
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Autistic voices are finally speaking in large numbers and it’s time to pay attention. No one else knows life with autism. Parents and nonautistic researchers are sometimes listening. Hard as this may be for them to hear, they are always guessing. With autistics speaking out all over the world, that’s no longer good enough. For the first time, IACC has recognized this in the 2017 Strategic Plan Update. They say it’s time for a paradigm shift in how we do research. We need to focus on the needs of people living with autism today. That’s a realization that I appreciate, and it’s long overdue. So what’s the answer to why we’ve gotten so little return on our autism research investment: No one asked the autistic people what we wanted. It’s that simple. Had we been able to articulate our challenges, with the framework of knowledge we have today, and had we been listened to, we’d be in a very different place today. Today is gone, but tomorrow isn’t here yet, and it can be different. (c) John Elder Robison John Elder Robison is an autistic adult and advocate for people with neurological differences. He’s the author of Look Me in the Eye, Be Different, Raising Cubby, and Switched On. He serves on the Interagency Autism Coordinating Committee of the U.S. Dept. of Health and Human Services and many other autism-related boards. He’s co-founder of the TCS Auto Program (a school for teens with developmental challenges), and he’s the Neurodiversity Scholar in Residence at the College of William and Mary in Williamsburg, Virginia, and a visiting professor of practice at Bay Path University in Longmeadow, Massachusetts. The opinions expressed here are his own. There is no warranty expressed or implied. While reading this essay will give you food for thought, actually printing and eating it may make you sick.
John Elder Robison is the author of Raising Cubby, Look Me in the Eye, My Life with Asperger’s, and Be Different – adventures of a free range Aspergian. John’s books are sold in a dozen languages in over 65 countries.
The study of human personality or ‘character’ (from the Greek charaktêr, the mark impressed upon a coin) dates back at least to antiquity. In his Characters, Tyrtamus (371-287 bc)—nicknamed Theophrastus or ‘divinely speaking’ by his contemporary Aristotle— divided the people of the Athens of the 4th century BC into thirty different personality types, including ‘arrogance’, ‘irony’, and ‘boastfulness’.
The Characters exerted a strong influence on subsequent studies of human personality such as those of Thomas Overbury (1581-1613) in England and Jean de la Bruyère (1645-1696) in France. The concept of personality disorder itself is much more recent and tentatively dates back to psychiatrist Philippe Pinel’s 1801 description of manie sans délire, a condition which he characterized as outbursts of rage and violence (manie) in the absence of any symp- toms of psychosis such as delusions and hallucinations (délires). Across the English Channel, physician JC Prichard (1786-1848) coined the term ‘moral insanity’ in 1835 to refer to a larger group of people characterized by ‘morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions and natural impulses’, but the term, probably considered too broad and non-specific, soon fell into disuse. Some 60 years later, in 1896, psychiatrist Emil Kraepelin (1856-1926) described seven forms of antisocial behaviour under the umbrella of ‘psychopathic personality’, a term later broadened by Kraepelin’s younger colleague Kurt Schneider (1887-1967) to include those who ‘suffer from their abnormality’. Schneider’s seminal volume of 1923, Die psychopathischen Persönlichkeiten (Psychopathic Personalities), still forms the basis of current classifications of personality disorders such as that contained in the influential American classification of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders 5th Revision (DSM-5). According to DSM-5, a personality disorder can be diagnosed if there are significant impairments in self and interpersonal functioning together with one or more pathological personality traits. In addition, these features must be (1) relatively stable across time and consistent across situations, (2) not better understood as normative for the individual’s developmental stage or socio-cultural environment, and (3) not solely due to the direct effects of a substance or general medical condition. DSM-5 lists ten personality disorders, and allocates each to one of three groups or ‘clusters’: A, B, or C Cluster A (Odd, bizarre, eccentric) Paranoid PD, Schizoid PD, Schizotypal PD Cluster B (Dramatic, erratic) Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD Cluster C (Anxious, fearful) Avoidant PD, Dependent PD, Obsessive-compulsive PD Before going on to characterize these ten personality disorders, it should be emphasized that they are more the product of historical observation than of scientific study, and thus that they are rather vague and imprecise constructs. As a result, they rarely present in their classic ‘textbook’ form, but instead tend to blur into one another. Their division into three clusters in DSM-5 is intended to reflect this tendency, with any given personality disorder most likely to blur with other personality disorders within its cluster. For instance, in cluster A, paranoid personality is most likely to blur with schizoid personality disorder and schizotypal personality disorder. The majority of people with a personality disorder never come into contact with mental health services, and those who do usually do so in the context of another mental disorder or at a time of crisis, commonly after self-harming or breaking the law. Nevertheless, personality disorders are important to health professionals because they predispose to mental disorder, and affect the presentation and management of existing mental disorder. They also result in considerable distress and impairment, and so may need to be treated ‘in their own right’. Whether this ought to be the remit of the health professions is a matter of debate and controversy, especially with regard to those personality disorders which predispose to criminal activity, and which are often treated with the primary purpose of preventing crime. 1. Paranoid personality disorder Cluster A comprises paranoid, schizoid, and schizotypal personality disorders. Paranoid personality disorder is characterized by a pervasive distrust of others, including even friends, family, and partner. As a result, the person is guarded and suspicious, and constantly on the lookout for clues or suggestions to validate his fears. He also has a strong sense of personal rights: he is overly sensitive to setbacks and rebuffs, easily feels shame and humiliation, and persistently bears grudges. Unsurprisingly, he tends to withdraw from others and to struggle with building close relationships. The principal ego defence in paranoid PD is projection, which involves attributing one’s unacceptable thoughts and feelings to other people. A large long-term twin study found that paranoid PD is modestly heritable, and that it shares a portion of its genetic and environmental risk factors with schizoid PD and schizotypal PD. 2. Schizoid personality disorder The term ‘schizoid’ designates a natural tendency to direct attention toward one’s inner life and away from the external world. A person with schizoid PD is detached and aloof and prone to introspection and fantasy. He has no desire for social or sexual relationships, is indifferent to others and to social norms and conventions, and lacks emotional response. A competing theory about people with schizoid PD is that they are in fact highly sensitive with a rich inner life: they experience a deep longing for intimacy but find initiating and maintaining close relationships too difficult or distressing, and so retreat into their inner world. People with schizoid PD rarely present to medical attention because, despite their reluctance to form close relationships, they are generally well functioning, and quite untroubled by their apparent oddness. 3. Schizotypal disorder Schizotypal PD is characterized by oddities of appearance, behaviour, and speech, unusual perceptual experiences, and anomalies of thinking similar to those seen in schizophrenia. These latter can include odd beliefs, magical thinking (for instance, thinking that speaking of the devil can make him appear), suspiciousness, and obsessive ruminations. People with schizotypal PD often fear social interaction and think of others as harmful. This may lead them to develop so-called ideas of reference, that is, beliefs or intuitions that events and happenings are somehow related to them. So whereas people with schizotypal PD and people with schizoid PD both avoid social interaction, with the former it is because they fear others, whereas with the latter it is because they have no desire to interact with others or find interacting with others too difficult. People with schizotypal PD have a higher than average probability of developing schizophrenia, and the condition used to be called ‘latent schizophrenia’. 4. Antisocial personality disorder Cluster B comprises antisocial, borderline, histrionic, and narcis- sistic personality disorders. Until psychiatrist Kurt Schneider (1887-1967) broadened the concept of personality disorder to include those who ‘suffer from their abnormality’, personality disorder was more or less synonymous with antisocial personality disorder. Antisocial PD is much more common in men than in women, and is characterized by a callous unconcern for the feelings of others. The person disregards social rules and obligations, is irritable and aggressive, acts impulsively, lacks guilt, and fails to learn from experience. In many cases, he has no difficulty finding relationships—and can even appear superficially charming (the so-called ‘charming psychopath’)—but these relationships are usually fiery, turbulent, and short-lived. As antisocial PD is the mental disorder most closely correlated with crime, he is likely to have a criminal record or a history of being in and out of prison. 5. Borderline personality disorder In borderline PD (or emotionally unstable PD), the person essentially lacks a sense of self, and, as a result, experiences feelings of emptiness and fears of abandonment. There is a pattern of intense but unstable relationships, emotional instability, outbursts of anger and violence (especially in response to criticism), and impulsive behaviour. Suicidal threats and acts of self-harm are common, for which reason many people with borderline PD frequently come to medical attention. Borderline PD was so called because it was thought to lie on the ‘borderline’ between neurotic (anxiety) disorders and psychotic disorders such as schizophrenia and bipolar disorder. It has been suggested that borderline personality disorder often results from childhood sexual abuse, and that it is more common in women in part because women are more likely to suffer sexual abuse. However, feminists have argued that borderline PD is more common in women because women presenting with angry and promiscuous behaviour tend to be labelled with it, whereas men presenting with similar behaviour tend instead to be labelled with antisocial PD. 6. Histrionic personality disorder People with histrionic PD lack a sense of self-worth, and depend for their wellbeing on attracting the attention and approval of others. They often seem to be dramatizing or ‘playing a part’ in a bid to be heard and seen. Indeed, ‘histrionic’ derives from the Latin histrionicus, ‘pertaining to the actor’. People with histrionic PD may take great care of their appearance and behave in a manner that is overly charming or inappropriately seductive. As they crave excitement and act on impulse or suggestion, they can place them- selves at risk of accident or exploitation. Their dealings with others often seem insincere or superficial, which, in the longer term, can adversely impact on their social and romantic relationships. This is especially distressing to them, as they are sensitive to criticism and rejection, and react badly to loss or failure. A vicious circle may take hold in which the more rejected they feel, the more histrionic they become; and the more histrionic they become, the more rejected they feel. It can be argued that a vicious circle of some kind is at the heart of every personality disorder, and, indeed, every mental disorder. 7. Narcissistic personality disorder In narcissistic PD, the person has an extreme feeling of self-importance, a sense of entitlement, and a need to be admired. He is envious of others and expects them to be the same of him. He lacks empathy and readily exploits others to achieve his aims. To others, he may seem self-absorbed, controlling, intolerant, selfish, or insensitive. If he feels obstructed or ridiculed, he can fly into a fit of destructive anger and revenge. Such a reaction is sometimes called ‘narcissistic rage’, and can have disastrous consequences for all those involved. 8. Avoidant personality disorder Cluster C comprises avoidant, dependent, and anankastic personality disorders. People with avoidant PD believe that they are socially inept, unappealing, or inferior, and constantly fear being embarrassed, criticized, or rejected. They avoid meeting others unless they are certain of being liked, and are restrained even in their intimate relationships. Avoidant PD is strongly associated with anxiety disorders, and may also be associated with actual or felt rejection by parents or peers in childhood. Research suggests that people with avoidant PD excessively monitor internal reactions, both their own and those of others, which prevents them from engaging naturally or fluently in social situations. A vicious circle takes hold in which the more they monitor their internal reactions, the more inept they feel; and the more inept they feel, the more they monitor their internal reactions. 9. Dependent personality disorder Dependent PD is characterized by a lack of self-confidence and an excessive need to be looked after. The person needs a lot of help in making everyday decisions and surrenders important life decisions to the care of others. He greatly fears abandonment and may go through considerable lengths to secure and maintain relationships. A person with dependent PD sees himself as inadequate and helpless, and so surrenders personal responsibility and submits himself to one or more protective others. He imagines that he is at one with these protective other(s), whom he idealizes as com- petent and powerful, and towards whom he behaves in a manner that is ingratiating and self-effacing. People with dependent PD often end up with people with a cluster B personality disorder, who feed on the unconditional high regard in which they are held. Overall, people with dependent PD maintain a naïve and child-like perspective, and have limited insight into themselves and others. This entrenches their dependency, and leaves them vulnerable to abuse and exploitation. 10. Anankastic personality disorder Anankastic PD is characterized by excessive preoccupation with details, rules, lists, order, organization, or schedules; perfectionism so extreme that it prevents a task from being completed; and devotion to work and productivity at the expense of leisure and relationships. A person with anankastic PD is typically doubting and cautious, rigid and controlling, humorless, and miserly. His underlying anxiety arises from a perceived lack of control over a world that eludes his understanding; and the more he tries to exert control, the more out of control he feels. In consequence, he has little tolerance for complexity or nuance, and tends to simplify the world by seeing things as either all good or all bad. His relationships with colleagues, friends, and family are often strained by the unreasonable and inflexible demands that he makes upon them. Closing remarks While personality disorders may differ from mental disorders like schizophrenia and bipolar disorder, they do, by definition, lead to significant impairment. They are estimated to affect about 10 per cent of people, although this figure ultimately depends on where clinicians draw the line between a ‘normal’ personality and one that leads to significant impairment. Characterizing the ten personality disorders is difficult, but diagnosing them reliably is even more so. For instance, how far from the norm must personality traits deviate before they can be counted as disordered? How significant is ‘significant impairment’? And how is ‘impairment’ to be defined? Whatever the answers to these questions, they are bound to include a large part of subjectivity. Personal dislike, prejudice, or a clash of values can all play a part in arriving at a diagnosis of personality disorder, and it has been argued that the diagnosis amounts to little more than a convenient label for undesirables and social deviants.