New Findings on the Link between Television and Autism Spectrum Disorders:
Developmental and Cultural Factors in the Prevalence of Autistic Disorder and Autistic Spectrum
Disorder
By Mark Germine
Introduction
During approximately 15 years as a child and adolescent psychiatrist, I have found myself faced
with a more severe and higher prevalence of ASD , especially Autistic Disorder. The principle
difference that distinguishes Autistic Disorder is impaired development in the use of language.
The infant of ordinary intelligence and adequate hearing generally begins to speak individual
words by 12 months, and a delay to 18 months or more is significant, the mean delay in
language in Autistic Disorder is about 11 months. Impairment of the ability to initiate and
sustain conversation, even without delayed speech is not adequate for the diagnosis, as are other
language criteria. A disturbance in tonal inflection of speech is very often seen.
Besides these language criteria, lack of emotional reciprocity, poor eye contact, preference of
solitary activities, are frequently seen in all of the ASD, while obsessive and restricted interests
and repetition of words and/movements are common features. Individuals who meet other
criteria but do not meet language criteria are diagnosed with Asperger’s Disorder, and these
individuals can be very successful, as compared to the much lower functioning typically seen in
Autistic Disorder, and the diagnosis can be more subtle.
Albert Einstein and other geniuses have been said to have had Asperger’s Disorder, and, if very
intelligent, the savant syndrome is often associated to produce genius. Savants seem to know or
intuit things without needed to figure them out, and, at all levels of the ASDs, may have
extraordinary abilities and talents. It is said that Einstein had essentially understood General
Relativity (E = mc2 etc.) long before a he understood the mathematics to formulate it, and
much this mathematics was learned from Minkowski, who is reported to have said he was the
worst student, at this level, that he had ever had. Apparently the mathematical formulation was
mere window dressing for a theory Einstein already understood.
There is also an interesting story of Louis Pasteur, who, upon receiving a prize in front of a large
group in Paris for his superior logic, said: “Logic is a sign of mediocrity” and that the “savant”
had no need for it. This was a rather un-social thing to say, even if he believed it. It reflected
what appeared to be distain for a people that adulated him, and this seems to fit with an ASD.
A good example of Autistic Disorder was portrayed by Dustin Hoffman, in the movie Rain Man.
The agitation when overwhelmed is classic, as well as the inflexible routines and repetitive
speech, and the affect or emotion was brilliantly portrayed. Napoleon Dynamite is used
as an example of Asperger’s Disorder, but is, to this author, at best an exemplar of very mild
ASD.
The ASDs are grouped under the rubric of pervasive developmental disorders (PDD), which
includes PDD not otherwise specified (PDD NOS), and this is the category used for those who
do not meet criteria for Autism or Aspergers. I can be very subtle, is very common, but is seldom
recognized. Autistic Disorder, in my experience, is more often missed than is generally believed.
I recently saw a 14 year old adolescent who had been mis-diagnosed by several clinicians of
various qualifications, for ten years, who clearly had Autistic Disorder. Everyone who meets
this diagnosis goes a tertiary center for validation of the diagnosis, as it qualifies for various
entitlements under the law.
Factors in the Development and Severity of ASDs
More often than not, psychiatric illness such as the ASDs are multifactorial, as are many medical
conditions. Cancer, for example, is related to genetic susceptibility as well as carcinogens such
as cigarette smoke and toxic substances. There may be many such factors. It is unquestionable
that the diagnosis of Autistic Disorder and ASDs has increased. This may be the result of
an increase in diagnosis, but, in my own experience, it is still often missed, and it may be
that it has become more severe, leading to more frequent diagnosis.
Various toxins have been ruled out, and the MMR vaccine has now been definitively ruled out,
with the unfortunate consequence that the avoidance of the vaccine has been associated with
many deaths from measles.
Genetic susceptibility for Autism is such that in 36-97% of identical twins,
variously reported, it will be concordant or develop in one twin if it develops in
the other. However, concordance makes certain assumptions about the conditions of
and, to the extent that the developmental predicates might be similar, there may not a true
genetic contribution to the extent of the concordance. In any event, this leaves a great portion of
the variance or factors fostering development of Autism to other factors, including
developmental variables and cultural factors.
Television and ASD
The autism rise began around 1980, about the same time cable television and VCRs became common, allowing children to watch television aimed at them any time. A study was conducted and controlled against other things, including petroleum consumption, and did not find a link, so it was, in fact, controlled. Although statistical association does not mean causality – it is very often used in this way in epidemiological studies. The studies hit with a big splash, and the researchers were attached is such way that they were never published in a professional journal, to my knowledge. The researches, who were Cornell health economists, stated: "Approximately 17% of the growth in autism in California and Pennsylvania during the 1970s and 1980s was due to the growth of cable television," and "just under 40% of autism diagnoses in the three states studied is the result of television watching due to precipitation." (Wallace, 2006; Easterbrook, 2006). These studies were fundamentally dismissed with great prejudice towards the authors and their conclusions.
In the meantime, the phenomenon of Infant Television and videos has skyrocketed: To quote a source (Scotman, 2004):
The Baby Channel offers 24 hours a day, seven days a week programming for children aged three and under… The Baby Channel's mission is simple: to entertain the tiniest members of society as and when they desire, including when they will not sleep… parents obviously think the service is worth paying for. But not everyone is so impressed.
The Baby Channel has been dismissed by some as little more than an electronic nanny, a device with which parents are abnegating their duty to interact one-to-one with their child. With the help of the remote control, your little ones can play simple interactive games…
Andrew Whiteman, the managing director of Kidstime Entertainment, the company which produces the channel's content, accepts that parents are likely to dump their babies in front of the TV while they get on with household tasks…today the market in on-screen baby entertainment is booming, and opinion on the consequences of this growing trend is split.
The Baby Bright videos were first launched in 2000 but next month it relaunches with an expanded range which includes DVDs. Designed for babies as young as three months, Baby Bright offers videos filled with colour, movement, sound, objects and music, based on scientific research into what really stimulates babies, and the range comes with some serious credentials.
Infants in the US are offered a similar alternative with the Baby Einstein videos, which were launched in 1996 with the slogan "Great Minds Start Little"…. More than one million Baby Einstein videos are believed to be sold in the US every year. It doesn't and shouldn't take the place of books or outdoor activities.
If you are in any doubt as to the industry feeling for the potential market for on-screen baby entertainment, the fact that the Walt Disney Company purchased Baby Einstein in 2001 gives some indication as to how this sector is expected to expand.
Liz Attenborough is manager of the National Literary Trust's Talk To Your Baby Campaign, which was set up last year amid concerns that increasing numbers of children were starting school with poorly developed communication skills.
The campaign has reviewed all available research on the subject of babies and television, and is in no doubt that excessive viewing can hinder the development of a child's verbal skills, which has a knock-on detrimental effect on their literary abilities. A survey of head teachers by the trust in 2002 found that more children were arriving at nursery education aged three without the language skills appropriate for their age. Vocabulary was considered to be less well developed than five years ago, with a reduced capacity to listen.
Ayr-based psychologist Agnes Steven, argues that this is the best policy to adopt. "Children will become slow developers verbally because they don't need to talk," she says of infants left to spend long periods in front of the screen. "If people live in fantasy from childhood, once they have to start interacting with people they have real problems in terms of communication skills."
One study found a strongly negative association between vocalization and language development, a main criteria for Autistic Disorder, associated with television in a group of 329 children aged 2 to 48 months (Christakis et al., 2009), concluding (554) : “Audible television is associated with decreased exposure to discernible human adult speech and decreased child vocalizations. These results may explain the association between infant television exposure and delayed language development.”
In a pre-publication issue of a prestigious, peer reviewed, medical publication, a well controlled study has been presented, (Chonchuaya et al., 2011) concluding: “There is an earlier onset and higher frequency of television viewing in autistic children compared with children with typical development.” The authors studied children (mean age 2.56) with Autism Spectrum Disorder (ASD), of which there were 44, versus 84 normal controls. The statistics were staggering. Those with ASD began to watch television significantly earlier than controls (6.44 ± 6.35 vs. 12.41 ± 6.00 months of age, p ≤ 0.0001*) and spent more time watching television than …controls (4.60 ± 1.91 vs. 2.06 ± 1.21 h/day, p ≤ 0.0001*). “Those with ASD appeared to watch more adult programmes than normal controls, and they were less likely to watch television with caregivers.” The significance of these findings, indicated by p values, as cited above, is twenty times the level of scientific significance accepted to reject the null hypothesis of NO association between ASD and television watching.
Figure 1: Increased prevalence of ASDs in the United States from 1996-2007. From Wikipedia.
The American Academy of Pediatrics (Cartan and Kalen, 2002) has long recognized the harmful
role of television on children, and has recommended no television for children under two years,
and less than 2 hours for children over two, but these recommendations seem to have made little
impact, particularly with marketing of media aimed at infants increasing.
Bahavioral Paradigm of Television Addiction
Evidence of the harmful effects on television and video media has generally been ascribed to
decreased interpersonal contact, but it cannot be ruled out that these media are of
more direct harm. The infant watching a television is, in effect, having a relationship to a
machine or device, devoid of an feeling or emotional reciprocity, and the programming has now
been tailored to events to provide a kind of self-stimulation that is characteristic of the ASDs.
These programs are designed by experts to be behaviorally rewarding, and are demonstrably
addicting, with the view in mind the infant and child will crave more, and with the added
feature of interaction which is so prevalent and harmful of an addiction as to be preferred over
human contact.
Such a behaviorist program detracts from the healthy rewards of human contact, and
may, like other addictions, override other rewards to such an extent that the autistic-like mode
of interaction with media becomes the primary reward, and interpersonal contact loses its
power and efficacy in the development of the social individual. This development is, therefore,
impeded or arrested, in combination with a genetic susceptibility towards ASDs.
Developmental Paradigm
It is important to look at the developmental stages that might be involved to
a fully explanatory model. We will adopt the stages of development of Margaret Mahler for
this purpose (from Browie, 2111):
Normal Symbiotic Phase. According to Mahler, this phase
extends from the first signs of conscious awareness at four to six weeks until
about five months of age. (Mahler originally called the first few weeks of
helpless infancy the “Normal Autistic Phase”, but later discarded this
designation). In the Normal-Symbiotic Phase the infant is now aware of its
mother, but has no sense of individuality of its own. The infant and mother are
as one, and there is a barrier between them and the rest of the world.
Separation-Individuation Phase. In this phase the infant breaks out of its
“autistic shell” and begins to connect with its environment and with the people
in it. Separation refers to the development of limits and to the
differentiation in the infant’s mind between the infant and the mother, whereas
individuation refers to the development of the infant's ego, sense of identity,
and cognitive abilities. This phase is divided into three sub-phases, which
occur in the following order, but which often overlap in time:
1) Hatching. [5 to 9 months]. The infant becomes aware of the
differentiation between itself and its mother. It becomes increasingly aware of
its surroundings and interested in them, using its mother as a point of
reference or orientation.
2) Practicing. [9 to 16 months]. The infant can now get about on its
own, first crawling and then walking freely. The infant begins to explore
actively and becomes more independent of its mother. The infant still
experiences itself as one with its mother.
3) Rapprochement. [15 months and beyond]. The young child once again
becomes close to his mother, but begins to differentiate itself from his mother.
The child realizes that his physical mobility demonstrates psychic separateness
from his mother. The toddler may become tentative at this point, wanting his
mother to be in sight so that, through eye contact and action, he can explore
his world.
Mahler further divided Rapprochement into three sub-stages:
A) Beginning. The young child is motivated by a desire to share
discoveries with his mother.
B) Crisis. The child is torn between staying connected with his mother
and venturing out from his mother and becoming more independent and adventurous.
C) Solution. The child resolves the above Crisis according to the
dictates of his own newly forming individuality, to his fledgling use of
language, and to his interaction with the temperament of his mother.
Lack of emotional reciprocity is the hallmark of the ASDs, in the literature and in this author’s
experience. It is something that can be felt and sensed early in the process of evaluation.
Psychology seems to have fostered the myth that nothing real flows between and among people,
that we interact, fundamentally, with projections or learned cognitive structure. It has become a
kind of folk religion, preached by various media, and fortified with behavioral rewards of
identification with identities and personas that are outside the realm of personal reality, in terms
of success, wealth, admiration, and the various fictions that the media portrays. This
phenomenon is ongoing, and destructive of true emotional relationship. In this sense, given
current media driven state of our cultures, we may be creating a kind of autistic culture. I find
that it is not unusual for families to have televisions in every room, at times numerous
large, flat screen televisions, in the bedrooms and other rooms, and children and
adolescent spending six hours or more a day with video games, often staying up at night to do
so and bringing their hand-held video games into my office lest they need engage on an
interpersonal level. These games generally have violent themes. Every individual in the
household or family generally watches their own television, which loses any value as a shared
experience. So, in many ways, culture provides a substrate for the lack of reciprocity
of ASDs.
In the development scheme of Mahler, the symbiotic stage of infancy is not marked by a self-
other relationship,. as the infant has not yet learned to make the self-other distinction. However,
disturbance in symbiosis, such as might be the case with the consuming mother who does
foster the movement into separation-individuation, may be one of many paths that manifest the
phenotype or partial phenotype to varying degrees from the genotype or partial genotype,
through the effect it has on the birth of the other in the psyche.
One of the first things I learned in evaluation of ASDs was the so-called cup test. It has limited
sensitivity, but seems to be highly specific. Two paper cups of the same design are shown to the
child or adolescent. A coin is placed under one cup, and the subject is asked which cup the coin is
under. The other, most often the mother, is asked to leave the room briefly, and say nothing when
she returns. The coin is then switched to the other cup. The subject is then asked which cup he or she
thinks the coin is under, and why. The object is to test the concept that other minds are separate
from the subjects mind. Individuals strongly afflicted will often think that, because they saw the
switch, the other saw the switch, having little or no concept of other minds as separate from their
own. This seems like a kind of generalized symbiosis, where other has not yet come to be as
separate. Otherwise, answers may vary, and it is the process underlying the answer that is
frequently there is an “I don’t know” answer to either which cup the other will select or what
reasoning is behind the choice, which is generally not seen in subjects outside the ASDs. This is a
theory of mind (ToM) test that seems simple to do and to interpret. The low sensitivity of the test indicates
that ToM deficits are not uniform across the population, are unlikely to be a core deficit, and can have
positive significance in the evaluation of ASD but not negative significance.
Separation-individuation is, in the developmental theory of Mahler, where the distinction of
other develops and grows. It is most likely in the “hatching” phase that the developmental failure
occurs – at least in the complete failure to develop language in severe Autistic Disorder. This is
when the other arises as being separate, and, as the function of language is interpersonal and
reciprocal, language is arrested of delayed. It is very difficult to miss the more extreme cases of
Autistic Disorder, but some remediation is possible if it is caught early.
The ASDs are by no means monolithic, there a many variations in signs, symptoms, and severity,
likely involving a polygenetic origin that is heterogeneous, but may develop in all cases, a
combined syndrome genetically sustained but differing in severity according to development,
a syndrome with some genetic propensity but a high level of developmental variability. The
plasticity of the brain allows for some subsequent development, but certain developmental stages
do not lend themselves to remediation.
Possible Social and Cultural Factors
Television and other media provide reinforcers that may override the need for interpersonal
relatedness, which is a step beyond the mere loss of time of true interpersonal contact with a
primary caregiver, Such media may infect and condition such interpersonal contacts according to
the impersonal exigencies that they promote. On a wider societal basis, our relationships are
becoming increasingly impersonal as we interact with and through artifice of computers
and other technologies. Narcissism is epidemic, with a good deal of antisociality, and is, perhaps, the only
alternative to varying degrees of autistic development.
Perhaps certain individuals find some degree of autism necessary for survival. Perhaps, assortative mating tends
bring these people together, leading perhaps to autistic parenting styles that do not foster
individuation. There are many possible solutions, perhaps many pathways, to the ASDs, but a
cultural phenomenon may be best explained culturally, and this may be why we have found it
so inexplicable in the fields of science and psychology, and why we deny its startling increase in
prevalence in recent years.
It seems quite remarkable, and overall political, that the possible developmental and cultural
contributions to this trend have been so little addressed. The ASDs are, after all, developmental disorders.
Simple observation of the way children play (Apendix) signals a kind of Autistic trend. My observation is
that there is complete continuum of disorders, with Aspergers’s grading into PDD NOS and PDD NOS grading
into the “normal” population, also known as the "broader phenotype" seen is relatives of ASD childrean,
Conclusions
The study just released on the strong association of ASD (Chonchaiya et., 2011) and television is a wake-up
call, which does not seem to have yet found its way to parents. It validates the previous study (Easterbrook,
2006), so strongly condemned for political reasons, to such extent that we can now see a large portion of
incidence and severity of ASDs arising from television and video media. The two studies are complimentary
in terms of validation. The one, showing a very highly significant relationship between onset and amount of
television viewing could be interpreted, causally, as meaning that children with ASD tend to watch
television at an earlier age and for greater time intervals, although this is a bit of a stretch. However, the
epidemiological study rules out such a spurious connection. The document appended gives some
further insight into the nature of this phenomenon. The author of this document seems to be appropriately
circumspect, given the massive injury we are inflecting on our infants, children, and adolescents, and so
recommends no television exposure all to pre-school children.
The locus of illness here may, to some degree, be our culture and its reliance of television and other media,
computers, and other devices, and also allowing mass addiction to video games. We have, fundamentally,
by engaging with the interface of electronic media, become an autistic culture, such that the penetrance or
expression of the ASD genotype is increased in both number and severity. In addition to this, there is
a growing inadequacy in the level and duration or interaction with the primary care giver – most often the
mother. Mothers return to work as early as 2 weeks after birth. We really need to be giving a full year of
support to primary care givers to be available for the infant – and encouraged and rewarded by society for this,
the most important of human functions.
References
Browie, R. Margaret Mahler and Separation Individuation Theory. Accessed 2/1711.
Chonchaiya, W, Nuntnerumit, P, and Pruksananunda, C. (2011) Comparison of television
viewing between children with autism spectrum disorder and controls. Acta
Pediatrica. pre-publication.
Christakis, DA, Gilderson, J.. Richards, JA, Zimmeman, SJ, Garison, MM, Xu, D, Grau,
MM., Gray, S, and Yapsand, U. (2009) Audible television and decreased adult words
infant vocalizations, and conversational terms Arch. Pediatr. Adolescent Med 163
554-558.
Cartain, LA and Kalm, RS (2002) Prevalence, correlates, and trajectories of television viewing
among infants and toddlers. Pediatrics 109, 634-642.
Easterbrook, G (2006) TV might cause autism. Slate Magazine.
Scotman (2004) Baby Boom in View. 4/30/04. http://www.nationalliteracytrust.net/talktoyourbaby/TVnews.html#ban
Wallace, C. (2006) Does watching TV cause autism? Time, 1020/06.
http://www.time.com/time/health/article/0,8599,1548682,00.html#ixzz1ELjk6AHP
Wikipedia. Epidemiology of Autism: http://en.wikipedia.org/wiki/Epidemiology_of_autism
Accessed 2/17/11.
Appendix
Play, Empathy and TV
by Patty Wipfler, August 2009 column for "The Connected
Parent" at Cleverparents.com
Q. It seems to me that children aren't playing with each other the way they used
to. Sometimes, it looks to me like they hardly play with each other at all--they
act out imaginary scripts, and they're each in their own little worlds, next to
each other. What can I do to get them really playing again?
* * *
I have to agree! Something important has happened gradually over the past 20 years to children's play. The play in schoolyards and preschools has slid toward more scripted acting. . . . An important determinant of a child's empathy and flexibility in play is how much TV and video programming he is exposed to. [emphasis in original]. . . .The TV or video experience tends to isolate the child. As he plays, his attention is on the images in his mind, not on the child next to him.
Does acting in terms of an internal script - as opposed to reacting and being sensitive to others - sound familiar? It certainly has tones reminiscent of autism.
As I have said, I fear to wade into this emotional debate, beyond noting that every reputable epidemiological and medical organization (Centers for Disease Control and Prevention, American Academy of Pediatrics, the Institute of Medicine of the National Academy of Sciences) says the science - and logic - do not support the thimerosal-in-vaccines explanation. Besides, autism has continued to grow despite mercury-free vaccines.
At the same time, of course, we cannot blame individual parents for something so widespread.
This leaves broad environmental effects. I find it hard to accept some specific toxin has so rapidly seeped into our worlds that it has caused a huge increase in this specific childhood psychosocial malady and no other measurable consequence within such a short period.
Is exposure to video entertainments from earlier and earlier ages a contributing factor to autism?
If this argument is correct, then the massive Baby Einstein industry was not only a giant hoax, but a dangerous one. According to a 2003 study, a third of all American families with children ages 6 months to 2 years old owned a Baby Einstein video. But research has found that, although infants become engrossed in these videos (there are Baby Mozarts, Baby Shakespeares, etc.) , they offer no intellectual benefits. As a result of this finding and threatened law suits, the Walt Disney Company, which produces Baby Einstein, is now offering refunds to purchasers.
What a strange world we live in, where commercial interests market products to parents who pray their children will become intellectually advanced, when the extreme opposite may be true.
Although it does not link autism and TV, the American Academy of Pediatrics recommends babies under the age of 2 should not view videos or television at all. Ms. Wipfler goes further: "It may sound radical in the electronic age, but I urge parents to set the policy that they watch TV only when the children are not present, and keep their children away from TV and videos until they are well into elementary school."
That's not going to happen! Of course, one prime motivator for parents' reliance on video babysitters is the rampant fear in our society of sending children outdoors due to the perceived threat from infections, kidnappings, violence, et al.
What a pickle we're in.
P.S. Several commenters (such as MJ) have questioned the association of television viewing with autism on the grounds that the latter is such a severe condition it can't be likened to a casual, everyday behavior.
There are four key characteristics of an Autism Spectrum Disorder:
1.
COMMUNICATION IMPAIRMENT: Individuals with Autism have difficulty in all areas
of communication; verbal & non-verbal. There is an absence of language
development, or a delay in the development of language in early childhood.
2. SOCIAL RELATIONSHIPS/INTERACTIONS: Difficulty with social relationships range
from indifference to others, to highly inappropriate behavior.
3. IMAGINATION &
CREATIVITY: Children with an Autism Spectrum Disorder are restricted in
their imaginative play. Play is often limited to one or two activities,
involving repetitive actions.
4. REPETITIVE & RITUALISTIC BEHAVIORS: Individuals with an Autism Spectrum
Disorder develop repetitive behaviors, rituals, and obsessions, which help them
to order their world, creating some predictability.
MJ - Don't these characteristics of the disorder suggest TV-inspired behavior? Rather than positing bizarre, unrelated sources for autism (what, if vaccines cause autism, is the relationship between mercury-poisoning and this list?), doesn't it make sense to explore these similarities? Terry's list of measured impairment in heavy youthful TV includes these: that children "uttered fewer vocalizations, used fewer words and engaged in fewer conversations"; and that heavy TV viewing "in early childhood can lead to behavioral problems and poor social skills."
If we consider autism to occur along a spectrum currently, noting more and less severe varieties of autistic syndromes and behavior, doesn't it make sense to view the continuities between a diagnosable disorder and the standard experiences of many children, especially since we can't identify anything else that has risen along with autism rates but which (unlike weather) seems to have such direct links to the traits in question?
P.S.S.:
Kids watch more than a day of TV each week
The latest figures from Nielsen have children's TV usage at an eight-year high.
Children's health advocates warn of adverse effects.