5/10/2013

Why do autistic people reverse pronouns? An extremely preliminary look at the literature

Elizabeth "Ibby" Grace of Tiny Grace Notes recently wrote a fascinating post about how reversing pronouns has affected her life (do read it, it's wonderful!).

"Pronoun reversal" means using the wrong pronoun for the meaning you're trying to convey--like saying "I" when you mean "you," or vice versa.  She writes:


Sometimes, although I think I seem to speak fairly fluently, I call myself “you.”
This is different from the idiomatic use of “you” as in “y’all” or “one” to indicate a belief that I have access to everyone else’s feelings or experience. It is an accidental usage that happens when I am tired or nervous or upset and it causes me to make statements I do not agree with, straight up. 
...When my friends tell me a story with other people in the story, if there are more than two characters, I may get lost in the pronouns.  The proverbial he-said/she-said story is often literally the best I can follow, and if there’s another he or she in the mix, I might stop you and say, hang on, will you tell me this again using everyone’s name and no pronouns?  This might happen even if the story is simple and obvious.  I do not know why.  It may not help if I know all the people.  It sometimes doesn’t even help if the sentences start with the correct person’s name!  I still can get mixed up, and keep stopping your story with confused questions about like, wait-wait, so Jeannie was driving the semi? Hehe no silly, Jeannie is three years old. Pronouns are not my friend.

Fortunately, as she points out, this is great for interacting with people who prefer non-binary gender pronouns!

Turns out, pronoun reversals are characteristic of autism, going all the way back to Kanner (who first described "autism" as a syndrome in 1943).  In fact, I'm writing this post because Ibby Grace asked for some citations.  This is a pretty new literature area for me, so it's an incredibly preliminary overview.  If you've ever researched language in autism, you won't learn anything new and will probably have corrections to make (please do!).  However, if pronoun reversals are also a new topic for you, maybe this post will be an interesting introduction.

Although one review claims pronoun reversals are unique to autism (Wilkinson 2008), they actually occur for a very short time (less than a year) in typically developing children in the very early stages of learning their native language.  And there's a good reason: pronouns are just conceptually harder than other nouns (Snagglebox has an amusing Tarzan and Jane cartoon illustrating this).  Most nouns refer to just one person, or thing, or category of things ("Mommy" always refers to the same person no matter what).  By contrast, a pronoun means something different depending on who's saying it--your "me" is my "you."  So it's not surprising young children would take a little while to figure it out.  And given that a lot of autistic people have delays in at least some aspects of language (e.g. late speaking, receptive vocabulary, syntax, or pragmatics), you might expect autistic kids to reverse pronouns for a longer time.  As of 2012 (Evans & Demuth), it's not entirely clear how long autistic people typically reverse pronouns.  But I imagine some autism researchers would be surprised that a well-educated wordsmith like Ibby Grace reverses pronouns.  (O.K., I'm mildly surprised myself, but mostly just fascinated.  We all have our "things;" this is just a particularly interesting "thing" to have).

A number of reviews on language in autism all take it as a given that pronoun reversal is an established characteristic (Rapin & Dunn 2003; Tager-Flusberg, 1994; Tager-Flusberg, Paul & Lord, 2005; Wilkinson 1998).  However, tracking down the actual empirical literature establishing this is a bit more difficult, especially as most seems to go back to the 1960s-1980's.  A few examples...

1. Kanner (1943) reported, among other examples, that "When he [the child] wanted his mother to pull his shoe off, he said 'Pull off your shoe.'"

2. Kwan Wai Yi (1998) compared Cantonese autistic mentally handicapped 7-15 year olds and typically developing 3-4 year olds' use of first and second person pronouns.  Autistic children did the best at understanding "you," followed by producing "I."  They did worse at comprehending "I" and worst at producing "you" accurately.  Autistic children made more errors both in comprehending these pronouns and in producing them.  They also produced a lot more reversals than the neurotypical children.  Also, neurotypical children were more likely than autistic ones to replace pronouns with proper nouns when they had difficulty. 
3. [TW for behaviorism]. One training study involved a preschooler with language delays who could not answer "my-your" questions and apparently could not use "his-her" pronouns effectively to answer questions.  The authors report that he improved in these skills after training (Hendler, Weisberg & O'Dell 1988).

4. In 1994, Ritvo and colleagues described the characteristics of undiagnosed parents of autistic children who met criteria for ASD.  Four of the 14 exhibited "pronoun reversal, word invention."
5. In other cases, autistic children avoided using pronouns at all, perhaps not wanting to use a difficult construction in front of an unfamiliar experimenter.  Rita R. Jordan (1989) found that 11 autistic children (matched to receptive vocabulary-matched neurotypical & mentally handicapped children) showed almost no pronoun reversals--but they often used proper names for themselves or other references instead of pronouns.  Lee, Hobson & Chiat (1994) found that autistic children with lower language ability were more likely to use their own proper names rather than personal pronouns during certain parts of the experiment, and their parents reported that they had personal pronoun difficulties in everyday life.  

In short, neurotypical scientists feel confident that pronoun reversals are an "autism thing," but they have yet to figure out why.  That hasn't stopped them from coming up with a long list of possible explanations, though!

Explanation 1: "My name is 'you'"
A longitudinal study compared pronoun reversals in a typically developing girl, Naima, and a boy named Ethan who was later diagnosed with Asperger's (Evans & Demuth, 2011).  The study--which Dr. Jon Brock describes in detail here--suggests that these children reversed pronouns in slightly different ways, and for different reasons.

The typically developing child, Naima, simply didn't understand the concepts behind the pronouns...until, suddenly, she did.

In Naima’s case, it seems that she simply failed to grasp this concept, thinking that “you” was really just another name for herself. It wasn’t that she sometimes got it right and sometimes got it wrong. Between the ages of 19 and 28 months, virtually every time she used “you” or “your”, she was actually referring to herself, sometimes with amusing results:Naima: "I think you peed in your diaper."Mother: "Just now?"Naima: "I think you did."Then, all of a sudden, something clicked. In Naima’s final two sessions at 29 and 30 months, every single pronoun was used correctly.    
...Naimah was an only child at the time of the study and spent most of her time alone with either her mother or her father. As a result, most of the speech she heard was directed at her. This in turn meant that almost every time she heard the word “you” it referred to her. It would be perfectly understandable if she thought of "you” as simply another name for herself.
Evans and Demuth note that the abrupt end of Naima’s pronoun reversal coincided with a family holiday. They speculate that the time spent with both mum and dad is what gave her the learning experience necessary to finally grasp the concept of “you”.
That wasn't Evan's problem.  Although he sometimes reversed "you" and "I," he also sometimes used these pronouns correctly, suggesting that he understood the concepts at least to some degree.  

Contrary to this study, an earlier study (Oshima-Takane & Benaroya 1989) suggests that autistic children might reverse pronouns for the same reason as Naima.  The researchers had autistic children observe and imitate pronouns directed to another person (in one condition) and to themselves (in another).  Autistic children did appear to benefit from hearing pronouns directed to another person.  It seems strange to me that a one-time lab visit would make an observable difference, given that even an only child would have more opportunities to observe their parents talking to others than that in their daily lives.

Explanation 2: Echolalia
Kanner thought autistic children reversed pronouns because of echolalia: they often repeated whole phrases without changing the personal pronouns to suit the new situation.  "The child, once told by his mother, 'Now I will give you your milk,' expresses the desire for milk in exactly the same words. Consequently, he comes to speak of himself always as 'you,' and of the person addressed as 'I'" (1943, p. 244).

Explanation 3: Self, Other, and Switching Between Them
Marcel Just and colleagues have proposed yet another, somewhat demeaning explanation of pronoun reversals. You can find a more detailed analysis of the study here at Dr. Jon Brock's blog.  In a neuroimaging study (Mizuno et al, 2011), he found that young autistic adults were slower and less accurate than neurotypical peers at a task that involved rapidly comprehending pronouns.  They also had less synchronized activity between the anterior insula (a deep frontal structure) and the precuneus (in the parietal lobe).  This desynchronization is consistent with a number of studies from Just's and other labs that indicate weaker connections in autism between far-flung brain areas--particularly between frontal and more posterior regions.  Unfortunately, Just describes the insula-precuneus connection here as underpinning a sense of self, and the ability to shift between the self and others:

"The psychology of self — the thought of one's own identity — is especially important in social interaction, a facet of behavior that is usually disrupted in autism," said Just..."Shifting from one pronoun to another, depending on who the speaker is, constitutes a challenge not just for children with autism but also for adults with high-functioning autism, particularly when referring to one's self," Just said. "The functional collaboration of two brain areas may play a critical role for perspective shifting by supporting an attention shift between oneself and others...Pronoun reversals also characterize an atypical understanding of the social world in autism. The ability to flexibly shift viewpoints is vital to social communication, so the autistic impairment affects not just language but social communication." 

(This interpretation doesn't follow straightforwardly from the neuroimaging results, by the way.  The insula is involved in countless emotions, including disgust, as well as the perceptions of one's own heartbeat and other body signals (Mizuna et al 2011).  The precuneus participates in a diverse array of functions, including visuo-spatial imagery, episodic memory retrieval, consciousness, and yes, processing having to do with the self.  Basically, Just argues, the insula is involved in self-awareness, while the precuneus is involved with self-processing and also helps in shifting attention, such as between a speaker and a listener).  

Explanations 4 & 5: What Reversals?!
Snagglebox isn't a scientist, but she did suggest a couple of plausible reasons.  First, "autistic kids often like to keep doing the same thing over and over, so mistakes can stick and take longer to correct themselves."  Second, it may take them longer to notice they're making a mistake:
"Self-correction using feedback from the environment is difficult for autistic kids because they don’t easily notice or copy other people’s behaviour (they might not be aware that they're the only one calling their aunty ‘him’). So again, mistakes tend to get repeated for longer because they doesn’t realise there’s anything to fix."
The Best Explanation?: It's All Too Much
The best explanation of all, though, was in Ibby Grace's own account: "it is an accidental usage that happens when I am tired or nervous and upset."  Evans & Demuth's (2011) study of Evan and Naima hints at this, as Jon Brock reports: 
reversed pronouns were more likely to occur in sentences that contained multiple pronouns. For example, at aged 22 months, Ethan was recorded saying “I got you out” when he should have said “You got me out”. 
For a small child still mastering complex sentences and pronouns, a sentence with multiple pronouns would be difficult.  It's not surprising that Ethan would have more problems in such a taxing situation.

If autistic people are more likely to reverse pronouns when they have to do something difficult or complex, it makes sense that a child like Ethan who understands pronouns would nonetheless have difficulty in a conversational context where one must shift back and forth between different pronouns.  "Switching perspective," whether or not it's intrinsically "hard" for autistic people (Evans & Demuth 2011; Mizuna et al 2011) is an additional demand that could be overtaxing..

A minor finding of Michelle Cheng's (2012) thesis suggests something similar. In this study, children interacted with their mothers for 30 minutes during a lab visit, and she analyzed children's utterances that included either pronouns or proper names.  Participanats were 18 typically developing 19-24 month olds, as well as ASD 24-42 month olds who were verbal and receiving ABA therapy.  

The main findings were that neither group made many pronoun reversals, but the ASD children made more.  Furthermore, their reversals followed a different pattern.  Autistic children tended to say "I" when they meant "you," while typically developing children tended to say "you" when they meant "I."  

But here's the interesting finding: mothers interacted with children in two sessions, structured and unstructured.  During the structured section, the mothers would engage their children in specific and often demanding tasks, such as book reading, tower building, decision making, or balloon/bubble blowing. During the unstructured section, the mother interacted with her child as if it were a typical, everyday play session at home.  Children reversed their pronouns more during structured play than non-structured play.  (Cheng doesn't specify whether "children" refers to typically developing children as well, or just autistic ones).

For a toddler, all of these tasks are hard, either because of cognitive demands or movement demands or both.  Maybe it's a multitasking problem--toddlers' attention is going to the demands of the task rather than to forming a correct sentence.  Maybe it's an energy depletion problem.  This particular study doesn't make it clear.

This "overtaxed" explanation for pronoun reversals seems most likely of all of these to explain why an autistic person would continue switching pronouns into adulthood.  

What do you think? 

References
Cheng 2012-Cheng, Michelle (2012). Longitudinal changes in pronoun reversals in children with Autism Spectrum Disorder & typically developing children. Honors scholar theses paper 227. http://digitalcommons.uconn.edu/srhonors_theses/227
Evans & Demuth 2011-Evans, K. E., & Demuth, K. (2012). Individual differences in pronoun reversal: Evidence from two longitudinal case studies*. Journal of child language39(1), pp. 162.
Hendler, Weisberg & O'Dell 1988-Hendler, Marc, Weisberg, Paul & O'Dell, Nicholle (1988). Developing the receptive & productive use of pronouns in an autistic child: use of modeling & programming for generalization. Child & Family Behavior Therapy vol. 9, iss. 3-4.
Jordan 1989-Jordan,, Rita R. (1989). An experimental comparison of the understanding and use of speaker-addressee personal pronouns in autistic children. International J. of Language & Communication Disorders vol. 24 Iss. 2, 169-179.
Kanner 1943-Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child 2, 217-250.
Kwan Wai Yi 1998-Kwan Wai Yi, Sonia (1998). Comprehension and production of first and second person pronouns in autistic children.  B.A. Dissertation, University of Hong Kong, Speech & Hearing Sciences.
Lee, Hobson & Chiat 1994-Lee, Anthony, Hobson, R. Peter, & Chiat, Shulamuth (1994). I, you, me, & autism: an experimental study. J. of Autism & Developmental Disorders vol. 24, iss. 2, pp. 155-176.
Mizuna et al 2011-Mizuno, Akiko, Liu, Yanni, Williams, Diane L., Kelle,r Timothy A., Minshew, Nancy J., & Just, Marcel Adam (2011). The neural basis of deictic shifting in linguistic perspective-taking in high-functioning autism. Brain doi: 10.1093/brain/awr151
Oshima-Takane & Benaroya 1989-Oshima-Takane Y. & Benaroya S. (1989). An alternative view of pronominal errors in autistic children. J. of Autism & Developmental Disorders Vol. 19 Iss. 1, 73-85.
Rapin & Dunn 2003-Rapin, Isabelle & Dunn, Michelle (2003). Update on the language disorders of individuals on the autistic spectrum. Brain & Development 25, 166-172.
Ritvo et al 1994-Ritvo, Edward R., Ritvo, Ria, Freeman, B.J. & Mason-Brothers, Anne (1994). Clinical characteristics of mild autism in adults. Comprehensive Psychiatry vol 35, no. 2 pp. 149-156.
Tager-Flusberg 1994-Tager-Flusberg, H. (1994). Dissociations in form and function in the acquisition of language by autistic children. Constraints on language acquisition: Studies of atypical children, 175-194.
Tager-Flusberg, Paul & Lord 2005-Tager-Flusberg, H., Paul, R., & Lord, C. (2005). Language and communication in autism. Handbook of autism and pervasive developmental disorders1, 335-364.
Wilkinson 1998-Wilkinson, Kirsta M. (1998). Profiles of language & communication skills in autism. Mental Retardation & Developmental Disabilities Research Reviews 4, pp. 73-79.