Book Review: "Neurotribes: The Legacy of Autism"

Steve Silberman's award-winning 2015 book "Neurotribes: The Legacy of Autism and How to Think Smarter About People Who Think Differently" is well worth your time, even if its 520 pages are nearly as dense and unwieldly as its mammoth title. Neurotribes is a comprehensive history of the emergence of the modern understanding of autism spectrum disorders. Silberman is an excellent storyteller, and this well written book is filled to the brim with compelling individual narratives with an enviable capacity to suck the reader in. 

Despite its marketing as a pop science book, the strength of Neurotribes lies not in its presentation of the science of autism (which is disappointingly superficial), but by placing the discovery of the autism spectrum in its historic and social context. Through the lens of autistic individuals and their families, we witness the trials and tribulations of the psychiatric profession over the twentieth century; watch with horror as the Nazis rise to power in Europe, and read about the disturbing links between fascist and liberal eugenic beliefs; we see the origins of science fiction as popular literature, the heady early days of the internet, as well as the origins of gay conversion therapy. Neurotribes, in this sense, joins the genre of 'hidden history' now common in the queer community, in which well-known history is re-interpreted and re-experienced through the lives of minorities we now recognise were there in the shadows all along. 

For those unfamiliar with autism, Silberman's main aim is to walk the reader away from popular misconceptions about the disorder rooted in the initial scientific description (a single syndrome, causing unique and devastating impairment in early childhood, that is relatively rare) to the modern consensus. The new understanding is embodied by the clinical description of autism as a spectrum of diverse conditions, which appears in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Silberman attempts to resurrect figures unknown to the general public who were ahead of their time in advocating the spectrum concept, such as Soviet psychologist Grunya Sukharaeva, German pediatrician Han Asperger and British psychiatrist Lorna Wing. Given widespread panic over the modern prevalence of autism and its cause, Silberman's history is a necessary and laudatory corrective. 

The author, though, is not a disinterested chronicler and his biases slip into the writing throughout the book. Silberman is writing a story, and he's clear who his heroes and villains are. He valorises certain characters in questionable circumstances and demonises others unfairly; the venom in his prose sometimes detracts from the broader analytic point he's trying to make. The truth is, all real humans are flawed heroes whose individual prejudices reflect the broader historical patterns at play in their time and who cannot be judged sensibly by the standards of a different time - a trap Silberman repeatedly falls into. 

Why a spectrum?

Ultimately, the concept of variance as a spectrum is vastly more useful than the formerly dominant scientific (and neo-Platonist) tendency in which every category is represented by an single ideal type. What's the scientific value in defining separate historical species of human when we know they coexisted and interbred with one another? What's the utility of a binary categorisation of sex when we know that even biological sex characteristics are multifaceted and rarely perfectly correlate with one another? And now that we understand that autism is a cluster of interrelated developmental variations, with potentially hundreds of possible genetic loci and scores of possible environmental triggers, the spectrum model helps us see the similarities beyond the superficial differences: more of the signal and less of the noise. 

Autism is characterised by both positive and negative traits, but these traits should be seen as part of the psychological whole of an individual, whose life outcomes will depend on whether or not they receive the material support and social environment they need to flourish. From an evolutionary perspective, autism and autism-like cognition are precisely the sort of neurological variance we might expect to see persist in a population, and which highlights the inherent flaw in seeing our biological legacy as perfectly adapted. Autism-related polymorphisms might convey enough of an advantage to some individuals to offset the fitness loss caused by its more extreme manifestations. As might have been predicted by Dual Inheritance Theory, cultures which are 'pre-adapted' to recognising and employing the skills of the neuro-diverse may be better off in the long run than those (horrifically catalogued in Silberman's book) that treat the disabled or different as a burden to eliminated.

Manufacturing Normality

Autism, alongside other mental disorders once considered nearly fatal diseases, is increasingly being recognised as a diagnosis that is socially disabling only for a given social context. No one should downplay the immense challenges that serious mental disorders confer on those diagnosed and their families. And yet, Silberman's book argues persuasively that both the long-term prognosis of those affected and the severity of their symptoms is in large part a function of the understanding and support offered by their carers. There is some truth to the observation that institutions create madness, especially when used by society as an instrument to control those it can't - or won't - otherwise accommodate.

Silberman is particularly astute on the issue of toxic parenting, and its roots in the way society positions parents as the "middle managers" in a vast authoritarian enterprise aimed at producing 'standardised' or 'normal' children. The social pressure place on parents to do their duty in producing perfectly conformist consumers manifests itself as a laundry list of detrimental practices, not least is the vulnerability of parents to fraudsters who promise a quick fix to problems parents don't have the resources or understanding to cope with. Silberman rightly skewers Andrew Wakefield (the promotor of the myth that vaccines cause autism), the anti-vaxxer movement and those peddling 'cures' for autism ranging from homeopathic placebos to potentially tortuous regimens. But he makes the point that the real blame lies with a culture that places unrealistic and impossible duties on parents without providing them the necessary time or resources to perform them.

I hate to sound like a social constructivist unnecessarily, but the boundary between disease and merely odd or unusual observations is often socially constructed: what some parents or doctors will fret over, others will shrug off as normal variation. There is a definite risk that that spectrum model of autism could lead to the medicalising of otherwise benign variance, much as the increase in screening for breast cancer in healthy individuals has led to an increase in medically unnecessary and occasionally risky surgeries.

However, given the current model of funding for social services, Silberman gives voice to the many parents and practitioners that support maintaining the disorder as the only way to ensure continued funding for autism healthcare. In this way, autism appears in the same awkward positions as gender dysphoria: it probably can't be completed demedicalised in the same way homosexuality was in the 1960s. Like trans-identified individuals, people with autism need special assistance and adjustments to manage what might otherwise become crippling social disabilities. Analogies between autism and gender dysphoria litter Neurotribes and in fact support one of its key messages: societies tend to behave as if it's easier to (coercively) change the individual to fit society than expect the whole of society to adapt around them. 

The geek disease

Silberman gestures repeatedly towards the aphorism that autism is more than just the 'geek disease', but as a tech journalist he's a tad too indulgent towards Silicon Valley and more than a little in love with the supposed genius of his chosen subjects. The book is overly prone to performing remote diagnosis of historical figures in science and technology  - a dicey proposition at best - and he obscures the stories of those diagnosed with true autism by mixing them rather freely with the narratives of "(male) engineers with autistic traits." It is generally recognised today that autism does not discriminate: that it affects the gifted and ungifted in equal measure. But the connection between autism and genius is a sexy story, and Silberman is perhaps more of a good story-teller than he is a journalist of science. 

Neurotribes is at its best when the author simply lets people with autism tell their stories in their own words. Situating the autism rights movement and the argument for greater recognition of neurodiversity in the context of earlier reforms opening society up to greater racial, sexual and gender diversity is the right approach. While I would have appreciated a greater emphasis on actual research into the causes of autism, it's true that we don't need to understand the biological roots of variance in order to adjust our societies to it (see also: gender identity). Intersectionality means, as I have mentioned before, letting minorities tell us what changes they need from society in their own voice: in giving voice to perhaps one of the largest minorities in the world, "Neurotribes: The Legacy of Autism" thus performs a valuable service. 

The Omnivore's Dilemma Redux: Understanding Anti-Vaxxers

The 'Omnivore's Dilemma' is an extremely useful concept for understanding some of the paradoxes in human behaviour and psychology. Put simply, if a being can eat anything in order to obtain the energy and nutrients it needs to live, then it faces a dilemma not of survival but rather of choice. Rather than struggling just to achieve its goals (survival), the omnivore must answer questions such as how best to achieve that goal safely, efficiently and sustainably. Culture provides one way to find those answers - social learning increases decision-making effectiveness by offering proven solutions to questions about what's safe to eat, where the best stuff is found and how to prepare it efficiently. 

Everyone who's shopped in a modern supermarket has had direct experience of the omnivore's dilemma: the paradox of choice we feel when selecting one breakfast cereal out of hundreds causes acute anxiety akin to that felt by our ancestors deciding on the day's hunt. In our daily lives we resolve these feelings by relying on a combination of innate biological preferences and learned behaviours - some of which may be adaptive and some of which may not be. Our taste buds tell us to indulge in sweet and fatty foods; our psychological openness to experience tilts the scale between trying a new brand or sticking with what we've had before; our upbringing nudges us towards the brands our parents trusted; or we seek to imitate the choice of celebrities who appear on marketing material. If we're being very careful (perhaps because we're resource constrained) we might even engage our System 2 reasoning and perform a cost-benefit calculation: i.e. which cereal will feed a family of four for the least dollars?

The omnivore's dilemma is not just about food: humans are behaviourial omnivores. Every action we take is the path of least resistance between the competing biases and impulses coded in our brains by biology and culture - and those psychological and cultural impulses are shaped by thousands, if not millions, of years of natural selection. As a result, our impulses make certain assumptions about the physical environment related to the environmental structure in which they became 'fixed' as part of our psyche. The Santa Barbara-type evolutionary psychologists speculate at length about the "environment of evolutionary adaption" (EEA) - but in reality there's a different environment for every trait. For example, our preference for sugary and fatty foods is likely rooted deep in pre-agrarian history, at a time when such energy sources were rare. But your learned preference for cheap cereal may adaptive only in the developmental environment of your childhood, when your family pinched pennies.  

Signals and Behaviour

In terms of game theory, a behaviour is produced by a strategy which in turn relies on a stable set of expectations about the state of the world. As behaviourial omnivores, we are open to new information ('signals') about the state of the world and can adjust our strategies accordingly. In fact, humans as a species are remarkably adept at signal recognition: from birth, we are natural mimics with a preternatural talent for both pattern recognition and imputing causation. The canonical example of this is movement in tall grass: not only will we notice a sign of change in the state of the world, our first instinct is to attribute an agent or cause to that change. It's very likely in fact, that these abilities are somewhat overtuned: agency bias may be one of the psychological underpinnings of belief in the supernatural as well as social, political and economic conspiracy-mongering: we see patterns that just aren't there. 

But signals about the state of the world may or may not be accurate, indeed, they may be intentionally falsified by other actors. How then do we select between them, particularly when trusting one signal over another (i.e. changing our expectations about the world) may result in vastly different behaviour? Let's connect this back to real-world politics: the information age provides every individual with almost unlimited opinions on every conceivable topic. We face a paradox of information: given that we can find information supporting any conceivable state of the world, how do we choose between them? The answer is the same as when we choose our breakfast cereal: we let our biological and learned biases and preferences take over and go for the option that causes the least anxiety. Everyone is likely to prefer information that re-enforces their pre-existing beliefs about the state of the world (confirmation bias); conservatives are likely to prefer information from sources they are already familiar with; authoritarians will preferentially imitate the bahviour of high-status individuals etc. Only rarely do we engage our rational mind and make a costly, independent assessment of the facts. 

Social media makes all of this harder, of course. It strips away much of the context of information signals, removing information about the reputation and status of the sender that we might rely on to make such judgements. Bad faith actors can intentionally manipulate our biases to spread 'fake news'. Some of these techniques are quite insidious: propagandists and marketeers delight in abusing our learned biases towards the scientific method by deliberating misinterpreting research or associating themselves with high-status scientific professions. They attack the character or reputation of opposing sources (in areas unrelated to the quality of the information they are providing), knowing that this reduces the odds the experts will be listened to. They mimic the affectations and talking points of thought leaders: privileging 'open dialogue', the rhetorical style of varsity debate, and the cultural signifiers of wealth. 

The anti-vaxxers' dilemma

Let's see how this might all work in practice. Imagine you're a skeptical cattle herder in a quasi-agrarian society. You have a short lifespan, in no small part because there's a one in three chance of dying from smallpox. One day, someone from a neighbouring village comes through and describes a behaviour in which people in his village take pustules from infected cows and rub them on the faces or wounds of their children. He or she swears they haven't had a smallpox outbreak in years. Do you imitate this behaviour, knowing that a sick cow will sometimes also make a child sick? Of course you wouldn't! You'd think the stranger and his village were mad. And you might be right: another village nearby sacrifices the elderly to the sky-god and claims the same results, and that's obviously just superstititous nonsense. 

And yet the village that practices variolation is correct. Over millennia, they will live longer, healthier lives: have more children, herd more successfully and eventually come to dominate the local economy. Your village of skeptics (and the nearby village of religious fundamentalists) can't compete. You either imitate their behaviour or go extinct. Those who are most comfortable with novelty adapt the quickest. Over time, the behaviour becomes fixed in the population: scientists investigate and confirm the germ theory of disease; institutions are establish to subsidise the practice and punish those that don't comply. Ritualisation may even set in, such that compliance with the norm becomes a reliable signifier of group identity, 

Now flip the script. You're a parent who lives in a society that practices widespread vaccination and regularly signals to you that vaccination is safe and effective. But one day, you encounter a signal that tells you the opposite: somehow a crank theory or conspiracy, a bad scientific study or new religious belief has penetrated through the cultural fog and established an information paradox. What is the omnivore to do? Here's the thing: were the new information stating that vaccines are dangerous correct (it's not, for the record) the fitness-increasing decision would be to accept the new signal, refuse to vaccinate your children despite the risks and spread the new signal as widely as possible. Over a lifetime, your child would be statistically fitter and healthier and may achieve a higher social status. But of course, the opposite is true. The same openness to novelty which is adaptive in one set of conditions is maladaptive in the other. 

But the individual doesn't have the benefit of seeing life as a multi-generational evolutionary simulation in which statistically significant statistical differences in average outcomes are meaningful. They have to make a decision to reduce their individual anxiety in the moment. So their biases go to work. Most of us trust the information we learned as children about vaccinnes being safe; we attribute elite status to the medical profession and the advice it offers; we are at least partly responsive to the directives of government so long as it doesn't directly affect our individual rights and interests. A tiny minority of individuals will react differently and accept the new signal: maybe their psychological sanctity trigger is more sensitive; maybe they're more libertarian than average, and are skeptical about 'received wisdom'; maybe their openness to new information is set a little looser than average. Overall, it's plausible that there's a correlation between 'progressive' traits and anti-vaxxer idiocy: because the same set of underlying biases cause both sets of behaviour.

Openness to new information and skepticism of authority are politically adaptive behaviours for many people, but mental toolkits that may be adaptive in many scenarios are not guaranteed to be adaptive in all of them. We never know the state of the world with any certainty, and the adaptiveness or otherwise of our behaviour can only be known over extremely long timescales. Population-level behaviours, norms and institutions may help us resolve the paradox of information in many circumstances, but not all. We therefore remain behaviourial omnivores - capable of considerable strategic flexibility both on an individual and social level. That flexibility is central to what makes progress possible, but doesn't guarantee it for either the individual or society as a whole.