Frampton Gwynette: Hello, welcome to the The Autism News Network. I’m [inaudible 00:00:02]. We are reporting from Montreal, Quebec, Canada, and I’m here with a special guest, Dr. Zack Warren from Vanderbilt University.

Zack Warren: Yeah.

Frampton Gwynette: Thank you.

Zack Warren: Thanks for having me.

Frampton Gwynette: Yeah, we’re excited. And how’s your meeting going so far?

Zack Warren: It’s good. It’s a lot to take in, but it’s going good.

Frampton Gwynette: Yeah, exactly. I was at the panel discussion yesterday on the technology. There’s so much happening in the era of technology with autism, isn’t there?

Zack Warren: It’s pretty impressive. That panel was really fortunate. I get to be sort of a discussant, and just the caliber of work that some of those folks are pulling out right now is just amazing.

Frampton Gwynette: Yeah. It’s unbelievable. I went to the poster session for technology-

Zack Warren: The tech demo stuff. Yeah.

Frampton Gwynette: The virtual reality stuff is just mind blowing. Speaking of virtual reality, I wanted to ask you like one, I worked with a lot of patients who have high functioning autism and so they have normal IQs, but for whatever reason, struggle to drive and I guess we can start with that. Like, why is it so difficult [inaudible 00:00:55] with autism to take on that task?

Zack Warren: Yeah, I think it’s probably a pretty complex answer in terms of some of the things. And for some individuals I think the barriers are different than others. One of the barriers, for sure, is really about, it’s a complex and challenging and daunting task. And we found also that I think every parent of an adolescent, whether they have concerns related to autism or not, is usually fairly terrified about their kids sort of driving. And sometimes kids, when they have differences in terms of attention or learning or other certain neurodevelopmental sort of complexities, sometimes there’s a caution about approaching that and saying like, “Are they ready for this? Are they can have the skills to really be able to do this and the way they need?” You know because we all want to keep our kids safe.

Zack Warren: And so I think that’s a little bit of a barrier sometimes, it’s pretty prominent.

Frampton Gwynette: You and so we’re based in Charleston, South Carolina, which does not have a well developed public transportation system. And so I’ve seen firsthand how isolating it is when one cannot drive. And it just kind of compounds some of the other social deficits that are there. But you guys are developing at Vanderbilt an interesting system to address that through technology.

Zack Warren: We’re trying, right. Yeah. So being able to drive or just being able to, as you said, have access to high quality transportation is a really important thing for quality of life. And yeah, I mean in Tennessee if you don’t drive and you live in certain components of Tennessee, there’s just not another sort of transportation option for you other than somebody else driving you. Ride sharing is changing that a little bit in some places.

Zack Warren: But I think being able to independently drive is a huge, huge sort of factor in terms of optimal sort of adaptive independence every time. So we’re trying to develop systems that say, “All right, well, sometimes if parents are concerned about whether this is the right next sort of step to get them going and or if kids may need extra supports or extra sort of training to be able to sort of launch in terms of that skill domain, how are we going to be able to do that?” You don’t want to put somebody behind an object that can literally have the consequences that driving can have. And off you go. And so one of the things that we have is sort of for a long time driving simulators. So this idea that you can just get behind the wheel and you can practice and you can do some of those things and that’s good.

Zack Warren: And I think it’s a really important thing and you can get behind the wheel experience that moves on from a VR perspective. But we found, and have hypothesized, that we might be able to do things that further enhance the capacity to be able to learn and to drive. One of those things is when you’re driving, you really need to be paying attention to a lot of different things. You need to be paying attention to how fast am I going? You need to be scanning sort of your mirrors. You need to be thinking… And it’s a continuous process. It’s not, you do it once, you check and you go, you have to kind of continually sort of be, have this dynamic awareness of what’s happening in your environment. So we’ve thought about wouldn’t it be neat if we could help folks and learn that process.

Zack Warren: So not only the performance of driving and you crash and you’re done, but if you’re not looking in the right place, is there a way a VR environment can tell where you’re looking and give you cues to really enhance your ability to appropriately be scanning your environment?

Frampton Gwynette: So they’ve got the goggles on.

Zack Warren: You can even do this in a non wearable form. Because wearable technologies is great in terms of some immersive experiences, but also some folks don’t really tolerate wearing those things that well. So you can just do it in creating sort of a screen-based sort of environment that would be similar to looking at your windshield. And if you’re not paying attention to the right targets, the eye tracker registers that and says, “Oh, well, actually you should be looking here,” can freeze and actually can help sort of the individual with the appropriate way of scanning within that environment.

Zack Warren: So if you’re not attending to the stop sign, if you’re not attending to a pedestrian, it can ensure that, “Oh, wait, before we move forward, we do that.” And so-

Frampton Gwynette: It will cue them?

Zack Warren: Yeah. And it will reinforce this appropriate way of processing the information. Right? And we think that’s key, not just sort of the consequences, sort of you got it wrong or right, and not to have a feedback but actually helping people process information efficiently. If you do that, that can generalize the dynamic environments. And that’s probably the most critical part. So we’ve been working on that and we’ve also been trying to say, “Well, when we learn things there’s sort of an adaptive role of anxiety in that process.” You’ve heard this story a number of times of if you have no anxiety, you don’t study for that test and you fail.

Zack Warren: If you have so much anxiety, you can’t study for the test and you fail. You have to have an appropriate level to kind of keep you alert and engaged and enough of that to be adaptive. So in addition to kind of having these gaze patterns, we said, “Well wouldn’t it be lovely to also register an individual’s experience in that environment?” If it’s too overwhelming, maybe we need to back that down to a level where they can start to process and learn more efficiently.

Zack Warren: So our adaptive sort of driving simulation sort of environments are trying to do both those things. To really look at gaze pattern physiology and feed that back into the system to really optimize an individual’s ability to drive.

Frampton Gwynette: So if their pulse goes up or if you feel like they’re getting more anxious, you could kind of gear down the-

Zack Warren: Absolutely. You can make a decision about how to kind of go next. And the interesting part about sort of complex sort of machine learning is that it makes these predictions, see what’s happened and then it makes another prediction. So it gets better and better over time. We develop an individual learning model for an individual within that environment.

Frampton Gwynette: I love how you said that because yesterday, as you were kind of wrapping up the session, you mentioned that we have a spectrum and yet the diagnostic process can be binary in that, yes, you have autism, no you don’t, but then you’ve used that word individual to say rather an individual with autism, but can we design treatments and assessments for individuals? Can you elaborate on that a little?

Zack Warren: It’s basically that. This dichotomy we have has been an important one for certain things. We’ve kind of said, “Well, we want to be able to kind of have a diagnosis because we think doing that will enable us to help an individual get closer to treatments or things that will help, or to help us really anchor expectations of where things are going to come.” But the more you really sort of work with human beings, you realize that we’re not all are or none.

Zack Warren: We have characteristics for us that vary in many, many, many different respects and we’re really usually talking about sort of continuo. We all can place ourselves in a continuo of social interaction or communication or what we’re interested in. Diagnosis is usually sort of when we’re thinking about, “Oh well, there are certain areas there that are getting in the way now and we want to attend to them.” But it’s not a magic line. It’s not as if there is a real yes, and a real no. It’s actually much more complex.

Frampton Gwynette: [inaudible 00:07:29] to discover.

Zack Warren: That’s absolutely right.

Frampton Gwynette: One of the themes in yesterday’s panel was that individuals with autism may orient, which means they might gaze preferentially towards non-humans versus humans. And so I’ve seen a number of presentations talking about ways to track that with technology and then also maybe use robots to help get them more engaged. But one of the background questions I had was why would people with autism orient more to a robot than a person?

Zack Warren: Right. It’s a really interesting question. I wish I had a great answer for you, but I don’t. I think there are probably different reasons why that happens for different individuals. I do think there are probably just some differences in terms of how our complex wiring, our complex sort of neurodevelopmental sort of brain architecture comes together to reinforce certain aspects of how we interact with an environment. I mean, there are things that we respond to differently, from sensory input to what we find interesting to other individuals within our environment.

Zack Warren: And for whatever reason that neuro architecture for some young individuals with autism is very responsive to technological cuing, robotic motion, those types of things. I don’t know why, but it’s really, it’s quite a powerful and replicated finding that at least for a certain percentage of kids, you see this difference in response. And that may be one of reasons that we see some of the difficulties with communication early on. If you’re attending tasks of your environment that aren’t related to social communication or the people, it may not present as many learning opportunities there. And so there’s something reinforcing about that activity of probably from differences in terms of sensory input that we see in a lot of kids with ASD.

Frampton Gwynette: Yeah. It really is consistent though. You’re right, I see it in my clinic all the time. Mom and dad and maybe a sibling, we might be having conversation about the child and the child may prefer to be in the corner playing with an inanimate object and happy as can be.

Zack Warren: It’s literally diagnostic. The ADOS literally has an item where it’s a clinician and the parent trying to get attention and then if they’re not doing it, we activate sort of an animatronic sort of robot and it’s that sort of response difference that is seems to be an early hallmark symptom for some kids with ASD.

Frampton Gwynette: Yeah, absolutely. Some of the participants in the Autism News Network, and these are adults with high functioning autism, have commented to me about how important online friends are in their life. I have one young man, he mentioned that he’s had some online friends for over 10 years and they’re all in the same clan on a certain game and that he counts them as close friends of his, where I think other people who are maybe outside of his world would say, “Hey, that’s not a real friend. Friends or someone that you meet with face to face.” I guess my two part question is what do you think of that statement and then do you think technology can help make the leap from the virtual world to a face to face world?

Zack Warren: Yeah. I think we’re all different in terms of what we think about in terms of what is meaningful social engagement. And for a lot of us, we’ve traditionally thought of that as sort of face to face interactions because, prior to a hundred years ago, we really didn’t have the ability to interact with other individuals without that type of face to face sort of scenario playing out. I think I find reward in different types of relationships myself. Not necessarily online per se, but I have work friends and I have friends in my neighborhood and I have my college friends.

Zack Warren: And actually the way that I interact with those folks right now, a lot of times is technologically mediated. Yeah. I don’t see my college roommate but once every five years. But we have this sort of idea of how we can connect apart from that. So it’s interesting to think about. So is my relationship with that friend different? Because we had that experience before and now it’s somehow more meaningful because we’re interacting with that. So I think we’re having to think differently about what it means to interact with other individuals via technology. And I think there are ways in which it can be probably wonderfully adaptive, wonderfully meaningful and rewarding. And they’re probably also some ways where it’s not.

Frampton Gwynette: Yeah. As you were talking, I was thinking about when I grew up, this was, believe it or not, we had cordless phones in high school. Before high school, we had phones, usually one phone upstairs with a long cord that could dragged from my sister’s bedroom or it’s in my bedroom depending on who was using the phone at that time. And now that’s all out the window. And usually you’re communicating by text and that’s so important for young people. That’s their lifeline to socialize. Yeah. So it has changed quite a bit. I think as a parent now, I’d kill to have my daughter on the telephone speaking with her friends now rather-

Zack Warren: Than texting all the time. Yeah, no, it’s different. It’s definitely different.

Frampton Gwynette: Yeah, exactly. Interestingly, I know Jeremy [inaudible 00:12:29] earlier was talking about outcome measures. And I don’t know if I had talked about this before, but we were talking about maybe, do you ever feel like there’s certain apps like Find my Friends where you can actually see how many people are close around you. Do you think it would ever be an outcome measure to say, “Hey, you spent 20 hours this month in a room with other people versus last month, you spent zero hours [inaudible 00:00:12:52]” Do you think they would ever be, just using location tracking through Apple or something like that?

Zack Warren: That’s pretty cool idea. People are doing this sort of social mapping or social network mapping. A lot of times they’ve related that to young children. So they’ll take that into a preschool environment and they’ll quantify the amount of time that they spend basically in proximity to other kids and they’ll actually come up with rankings of preferred kids from the way that certain characteristics of the teacher is seeing in that environment and seeing how often they’re intersecting with certain different types of kids. Some of that, and Daniel Messinger is doing some of this work at the University of Miami right now, I think it’s probably a better measure than asking people one, two, three, how social is your child?

Zack Warren: To actually see where are you spending your time? Where you’re spending your time is a huge predictor of a lot of social outcomes. If you think about some of these studies, I’m going back to my college days for some reason, but the biggest predictor of friendships when you start college is who you’re living near. Your friendships really become those people that you live in close proximity to. Who you’re around who you’re spending time with. And so there’s something to that idea of we could be thinking about a physical map or we could think about sophisticated ways of quantifying how much time we’re spending in online communication.

Zack Warren: We might even be able to talk about sort of different quality sort of indicators within that type of communication over time, which would be fascinating to do.

Frampton Gwynette: Yeah, absolutely. And for those in our audience who don’t know, I was just talking about the human element of diagnosing autism. Dr Warren’s been really on the cutting edge of diagnosing autism, autism prevalence and has done probably thousands of what we call ADOS evaluations. Right?

Zack Warren: Yeah.

Frampton Gwynette: And so that’s the autism diagnostic observation schedule. And the great thing about the ADOS is it gives us a real useful tool of diagnosing autism. The downside is availability of that evaluation. I know yesterday you had mentioned how much do humans need to be embedded in the diagnostic process? Do you feel like that we’re headed towards a path where we can actually rely heavily on computers and machine learning to give us a good idea about diagnosis and therefore getting a diagnosis more readily, faster, younger ages?

Zack Warren: I hope we are. And that statement’s kind of provocative. But I’ve worked in clinics for the past 13 years where you just see families struggling to come up with the answers about how they can help their kids. And we oftentimes you’re creating situations where we’re saying, “Well, I’m really concerned about your child. He may have a lifelong neurodevelopmental sort of disability. I’ll let you know an answer to that question in six to 12 months.” And as a parent, I would not tolerate that for my child. You probably wouldn’t either. We would use sort of our resources and our connections and our networks to try and make those things happen. And that shouldn’t be our system of care. We shouldn’t be doing this to folks. And so I think we really have to challenge ourselves in saying, “Hey, what we’re doing currently isn’t working for who we want to work it for. And so how can we appropriately use some new tools, use some new technologies to really link kids and families to help?”

Zack Warren: And I think if you can frame it in that perspective, that comes a little bit less threatening. But I still think it’s pretty threatening, people who have been using these tools for a long time and they’re sort of seen as sort of gold standards. Or people use that. The ADOS is the gold standard. Well, there was a reason in our country, long time ago, that we actually moved our currency or away from the gold standard. We needed to become more agile to make decisions that could really, on a wholly different scale, provide us with the resources to tackle certain problems. And I think that’s similar to what we need to be thinking about in the autism world.

Zack Warren: How do we move towards new systems that help us make quick decisions and link families to help? Maybe that’s not necessarily doing things in a binary way. You’re state of South Carolina has done some interesting things where they’ve been able to talk about… Maybe we can talk about moving on risk. Maybe we can use a immediately available tool to just say there’s enough risk that we should be helping, while we figure out some of the complexities over time. Now that’s not a perfect solution and that’s had some challenges in terms of implementation. But that idea, I think has great power to it over time.

Frampton Gwynette: Yeah, absolutely. And being in South Carolina the data shows that if a parent is involved in either healthcare or education, that child will be diagnosed younger. The flip side of that is, and I see this every day, is if the child’s parents maybe are not in education or health care, let’s say the parents didn’t graduate high school or, God forbid, you’re in a small town or let’s say your parents primarily speak Spanish, which is not that rare. The access services really just goes off a cliff.

Zack Warren: It does. I mean, I think that’s a really important thing for us to think about. That model care that we’ve had has only worked for a very select few individuals and it has had a disproportionate sort of negative effect on underserved populations, for sure.

Frampton Gwynette: Yeah, no question. And then I want them to get back to virtual reality and I forgot to ask one question. I, to be honest, don’t understand this completely. So if you’re doing the virtual reality intervention, how does taking brainwaves or EEG benefit the researchers in that work?

Zack Warren: Yeah. So that’s been one of the components of it, that’s been, for us, a little bit more experimental, but we talked a little bit earlier, in that driving paradigm, if we knew actually sort of your physiology, if we knew where you were looking at things, we might be able to be able to make enhanced decisions about what happens next.

Zack Warren: The next level of that is actually looking at sort of neuro markers and understanding can we identify precursor sort of activities that are happening? Or understand sort of specific types of responses that may be important for what we want to do next. That’s one of the paradigms where we’re going to have to rely, I think, a lot on some of these complex machine learning models. Because it’s not apparent to our naked eye about what should we be doing with this? But those brain signals are terribly important to understanding sort of processing information. So that’s why we’ve been collecting some of that data, in that hope that over time we’ll be able to understand in a level that we don’t quite understand it now.

Frampton Gwynette: Yeah, exactly. I know lot of patients with autism have seizures and certain EEG is used to diagnose those. You’re not looking for seizures, you’re just looking for things like anxiety or or-

Zack Warren: Yeah, or how information is being processed. It can be another component of thinking about… We think about engagement, about how we’re looking at things. We think about engagement in terms of physiology and how our bodies are responding. You can think about that on a neural level too. Are we presenting the right type of environment for really helping an individual learner? All those different levels.

Frampton Gwynette: Gotcha. Okay. Well I’m going to totally switch gears and just ask you, do you have a college football team?

Zack Warren: So I grew up in Blacksburg, Virginia.

Frampton Gwynette: Oh, you did?

Zack Warren: I did.

Frampton Gwynette: Virginia Tech.

Zack Warren: That’s where Virginia tech is. So that’s the closest I have to a football fan.

Frampton Gwynette: That’s awesome. My college roommate was from Marion, Virginia. Not far.

Zack Warren: Oh, yeah. Not far.

Frampton Gwynette: Yeah. Cool. And so as you know, Charleston is a college football hotbed.

Zack Warren: Absolutely.

Frampton Gwynette: And so we ask all of our guests this, even though we’re in Canada, if pressed, would you say Carolina or Clemson?

Zack Warren: I’d have to say go Cox, I believe. Yeah, I think I really would. Yeah.

Frampton Gwynette: Okay. That’s my team as well. All right. And then you recently visited Charleston.

Zack Warren: I did.

Frampton Gwynette: Were there any highlights of your trip?

Zack Warren: The people, so you have some fabulous people that worked down there at MBOC that really helped me launch and have some of the opportunities that I’ve been able to have as a professional and it’s so rewarding to get to come back to a place where you trained. It’s just a very flattering sort of experience. So that was a highlight for me, and the food.

Frampton Gwynette: OH, the food, absolutely. I know Nashville is exploding in growth. Did you feel like Charleston has gotten bigger?

Zack Warren: Charleston has gotten a lot bigger in my eyes too. Yeah, it really has. I remembered some things, but a lot of the stuff I was like, “Wow, this place looks different to me.” Yeah, it was a fun time.

Frampton Gwynette: Yeah. That’s awesome. So going forward, are there any particular topics that you feel like the autism news network should consider covering or advice that you would give to us?

Zack Warren: I think talking to as many people as you can. Because I think there are varied perspectives on where we are right now, and I think it’s through that transparent engagement with people who have differing opinions about where we are, that we’re going to help each other move forward over time.

Frampton Gwynette: Yeah. Isn’t that funny? How we’re here to study autism, which is fundamentally about possibly impaired interactions and then really our connections with other people here at this meeting can help address that condition.

Zack Warren: Yeah. Yeah. It’s cool. It’s a cool meeting to be at. This is a really cool opportunity for me too.

Frampton Gwynette: Well, thanks for being here today. I appreciate it.

Zack Warren: Yeah. I really liked that. Thanks a lot.

Frampton Gwynette: I’m here with Dr Zack Warren, The Autism News NetWORK, from Montreal, Quebec, Canada. Thanks for watching.