Alexithymia

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Alexithymia is considered to be a personality trait that places individuals at risk for other medical and psychiatric disorders while reducing the likelihood that these individuals will respond to conventional treatments for the other conditions. Alexithymia is not classified as a mental disorder in the DSM-IV. It is a dimensional personality trait that varies in severity from person to person. A person's alexithymia score can be measured with questionnaires such as the Toronto Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questionnaire (BVAQ), or the Observer Alexithymia Scale (OAS).

Alexithymia is defined by:

difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal
difficulty describing feelings to other people
constricted imaginal processes, as evidenced by a scarcity of fantasies
a stimulus-bound, externally oriented cognitive style.

In studies of the general population the degree of alexithymia was found to be influenced by age, but not by gender; the rates of alexithymia in healthy controls have been found at: 8.3% (2 of 24 persons); 4.7% (2 of 43); 8.9% (16 of 179); and 7% (4 of 56). Thus, several studies have reported that the prevalence rate of alexithymia is less than 10%. A less common finding suggests that there may be a higher prevalence of alexithymia amongst males than females, which may be accounted for by difficulties some males have with "describing feelings", but not by difficulties in "identifying feelings" in which males and females show similar abilities.

The alexithymia construct is strongly inversely related to the concepts of psychological mindedness and emotional intelligence and M. Bagby and G. Taylor state that there is "strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress". Other opinions differ and can show evidence that it may be state-dependent.

Bagby and Taylor also suggest that there may be two kinds of alexithymia, "primary alexithymia" which is an enduring psychological trait that does not alter over time, and "secondary alexithymia" which is state-dependent and disappears after the evoking stressful situation has changed. These two manifestations of alexithymia are otherwise called "trait" or "state" alexithymia^.

Description

Typical deficiencies may include problems identifying, describing, and working with one's own feelings, often marked by a lack of understanding of the feelings of others; difficulty distinguishing between feelings and the bodily sensations of emotional arousal; confusion of physical sensations often associated with emotions; few dreams or fantasies due to restricted imagination; and concrete, realistic, logical thinking, often to the exclusion of emotional responses to problems. Those who have alexithymia also report very logical and realistic dreams, such as going to the store or eating a meal. Clinical experience suggests it is the structural features of dreams more than the ability to recall them that best characterizes alexithymia.

Some alexithymic individuals may appear to contradict the above mentioned characteristics because they can experience chronic dysphoria or manifest outbursts of crying or rage. However, questioning usually reveals that they are quite incapable of describing their feelings or appear confused by questions inquiring about specifics of feelings.

According to Henry Krystal, individuals suffering from alexithymia think in an operative way and may appear to be superadjusted to reality. In psychotherapy, however, a cognitive disturbance becomes apparent as patients tend to recount trivial, chronologically ordered actions, reactions, and events of daily life with monotonous detail. In general, these individuals lack imagination, intuition, empathy, and drive-fulfillment fantasy, especially in relation to objects. Instead, they seem oriented toward things and even treat themselves as robots. These problems seriously limit their responsiveness to psychoanalytic psychotherapy; psychosomatic illness or substance abuse is frequently exacerbated should these individuals enter psychotherapy.

A common misconception about alexithymia is that affected individuals are totally unable to express emotions verbally and that they may even fail to acknowledge that they experience emotions. Even before coining the term, Sifneos (1967) noted patients often mentioned things like anxiety or depression. The distinguishing factor was their inability to elaborate beyond a few limited adjectives such as "happy" or "unhappy" when describing these feelings. The core issue is that alexithymics have poorly differentiated emotions limiting their ability to distinguish and describe them to others. This contributes to the sense of emotional detachment from themselves and difficulty connecting with others, making alexithymia negatively associated with life satisfaction even when depression and other confounding factors are controlled for.

Relational issues

According to Vanheule, Desmet and Meganck (2006) alexithymia creates interpersonal problems because these individuals avoid emotionally close relationships, or that if they do form relationships with others they tend to position themselves as either dependent, dominant, or impersonal, "such that the relationship remains superficial". Inadequate "differentiation" between self and others by alexithymic individuals has been observed by Blaustein & Tuber (1998) and Taylor et al. (1997).

In a study, a large group of alexithymic individuals completed the 64-item Inventory of Interpersonal Problems (IIP-64) which found that "two interpersonal problems are significantly and stably related to alexithymia: cold/distant and non-assertive social functioning. All other IIP-64 subscales were not significantly related to alexithymia."

Chaotic interpersonal relations have also been observed by Sifneos. Due to the inherent difficulties identifying and describing emotional states in self and others, alexithymia also negatively affects relationship satisfaction between couples.

In a 2008 study alexithymia was found to be correlated with impaired understanding and demonstration of relational affection, and that this impairment contributes to poorer mental health, poorer relational well-being, and lowered relationship quality.

Some individuals working for organizations in which control of emotions is the norm might show alexithymic-like behavior but not be alexithymic. However, over time the lack of self-expression becomes part of their everyday lives and they end up losing their original self-identity.

In medical and psychiatric illness

Alexithymia frequently co-occurs with other disorders, with a representative prevalence of 85% in autism spectrum disorders, 40% in posttraumatic stress disorder, 63% in anorexia nervosa, 56% in bulimia, 45% in major depressive disorder, 34% in panic disorder, and 50% in substance abusers. Alexithymia also occurs in individuals with acquired or traumatic brain injury.

Research indicates that alexithymia overlaps with Asperger syndrome. In a 2004 study, Uta Frith reported an overlap and that at least half of the Asperger syndrome group obtained scores on the Toronto Alexithymia Scale (TAS-20) that would classify them as severely impaired. Fitzgerald & Bellgrove pointed out that, "Like Alexithymia, Asperger's syndrome is also characterised by core disturbances in speech and language and social relationships". Hill & Berthoz agreed with Fitzgerald & Bellgrove (2006) and in response stated that "there is some form of overlap between alexithymia and ASDs". They also pointed to studies that revealed impaired Theory of Mind skill in alexithymia, neuroanatomical evidence pointing to a shared etiology and similar social skills deficits. The exact nature of the overlap is uncertain. Alexithymic traits in AS may be linked to depression or anxiety; the mediating factors are unknown and it is possible that alexithymia predisposes to anxiety.

Alexithymia is correlated with certain personality disorders, substance use disorders, some anxiety disorders, and sexual disorders, as well as certain physical illnesses, such as hypertension, inflammatory bowel disease, and functional dyspepsia. Alexithymia is further linked with psychosomatic disorders such as migraine headaches, lower back pain, irritable bowel syndrome, asthma, nausea, allergies, and fibromyalgia.

An inability to modulate emotions is a possibility in explaining why some alexithymics are prone to discharge tension arising from unpleasant emotional states through impulsive acts or compulsive behaviors such as binge eating, substance abuse, perverse sexual behavior, or the self-starvation of anorexia nervosa. The failure to regulate emotions cognitively might result in prolonged elevations of the autonomic nervous system (ANS) and neuroendocrine systems which can lead to somatic diseases. Alexithymics also show a limited ability to experience positive emotions leading Krystal (1988) and Sifneos (1987) to describe many of these individuals as anhedonic.

Causes

It is unclear what causes alexithymia, though several theories have been proposed. There is evidence both for a genetic basis, meaning some people are predisposed to develop alexithymia, as well environmental causes.

Early studies showed evidence that there may be an interhemispheric transfer deficit among alexithymics; that is, the emotional information from the right hemisphere is not being properly transferred to the language regions in the left hemisphere, as can be caused by a decreased corpus callosum, often present in psychiatric patients who have suffered severe childhood abuse. A neuropsychological study in 1997 indicated that alexithymia may be due to a disturbance to the right hemisphere of the brain, which is largely responsible for processing emotions. In addition, another neuropsychological model suggests that alexithymia may be related to a dysfunction of the anterior cingulate cortex. These studies have some shortcomings, however, and the empirical evidence about the causes of alexithymia remains inconclusive. Joyce McDougall objected to the strong focus by clinicians on neurophysiological at the expense of psychological explanations for the genesis and operation of alexithymia, and introduced the alternative term "disaffectation" to stand for psychogenic alexithymia. For McDougall, the disaffected individual had at some point "experienced overwhelming emotion that threatened to attack their sense of integrity and identity", to which they applied psychological defenses to pulverize and eject all emotional representations from consciousness. A similar line of interpretation has been taken up using the methods of phenomenology.

French psychoanalyst, Joyce McDougall, noted that all infants are born unable to identify, organize, and speak about their emotional experiences (the word infans is from the Latin "not speaking"), and are "by reason of their immaturity inevitably alexithymic". Based on this fact McDougall proposed in 1985 that the alexithymic part of an adult personality could be "an extremely arrested and infantile psychic structure". The first language of an infant is nonverbal facial expressions. The mother's emotional state is important for determining how any child might develop. Neglect or indifference to varying changes in a child's facial expressions without proper feedback can promote an invalidation of the facial expressions manifested by the child. The parent's ability to reflect self-awareness to the child is another important factor. If the adult is incapable of recognizing and distinguishing emotional expressions in the child, it can influence the child's capacity to understand emotional expressions.

Although environmental, neurological, and genetic factors are each involved, the role of genetic and environmental factors for developing alexithymia is still unclear. The results from a large population-based sample of Danish twins suggest that genetic factors have a noticeable and similar impact on all facets of alexithymia. While the results suggested a moderate influence of shared environmental factors, results are in concordance with the general finding that environmental influences on most psychological traits are primarily of the nonshared rather than the shared type. One hypothesized environmental cause is head injury; persons suffering a traumatic brain injury are six times more likely to exhibit alexithymia.

Few people are familiar with the condition known asalexithymia, yet it is not so rare a thing. Alexithymia is condition where a person seems devoid of emotion because they are functionally unaware of their emotions. By extension, alexithymics are also unable to appreciate the emotional motivation of others, and generally find emotions of others to be perplexing and irrational. Such a person may be pleasant and highly intelligent, but will be humorless, unimaginative, and have some unusual priorities in decision-making.

Emotions have evolved as the mind’s way of shooting from the hip when gauging priorities, in order to protect our own interests. Something that triggers little or no emotion is typically an unimportant event which requires little attention, while something that causes high emotions is just the opposite. Fear, anger, happiness, confusion… these and other emotions all originate as signals from the subconscious to separate the trivial from the important, and they make highly useful logical shortcuts in decision-making. When stripped of this ability, the mind loses much of its effectiveness in prioritizing, causing the relevant and irrelevant to be given incorrect relative importance. For this reason, persons with alexithymia tend to be highly indecisive and inconsiderate.

As a side effect of their condition, alexithymics have impaired senses of imagination and creativity. The mind usually combines emotional information with rational when imagining scenarios, but the alexithymics’ will be missing any emotional content.

Some cases of alexithymia are neurological, meaning that it is caused by a deficiency in the brain pathways that process emotion. Others develop psychological alexithymia as a self-defense measure against the emotionally indigestible, such as terminal illness, or post-traumatic stress disorder. As a coping mechanism, the mind simply shuts down the pathways that process emotions, resulting in a stoic, emotionless state. This type of alexithymia is usually reversible through psychotherapeutic means, and sometimes with the help of anti-depressants.

Instructions: Answer the following questions as spontaneously as possible. If you get stuck on a question, leave it out and continue with the next. Each question can have one of 5 possible answers. These are:
Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree


1. - When asked which emotion I'm feeling, I frequently don't know the answer.


2. - I'm unsure of which words to use when describing my feelings.


3. - I prefer to find out the emotional intricacies of my problems rather than just describe them in terms of practical facts.


4. - When other people are hurt or upset, I have difficulty imagining what they are feeling.


5. - People tell me to describe my feelings more, as if I haven't elaborated enough.


6. - Sex as a recreational activity seems kinda pointless.


7. - I can describe my emotions with ease.


8. - You cannot functionally live your life without being aware of your deepest emotions.


9. - People sometimes get upset with me, and I can't imagine why


10. - People tell me I don't listen to their feelings properly, when in fact I'm doing my utmost to understand what they're saying!


11. - When I am upset I find it difficult to identify the feelings causing it.


12. - Describing the feelings I have about other people is often difficult.


13. - I prefer doing physical activities with friends rather than discussing each others’ emotional experiences.


14. - I am not much of a daydreamer.


15. - I don't like people's constant assumptions that I should understand or guess their needs... its as if they want me to read their minds!


16. - I sometimes experience confusing sensations in my body.


17. - For me sex is more a functional activity than it is an emotional one


18. - Some people have told me I am cold or unresponsive to their needs.


19. - I don't dream frequently, and when I do the dreams usually seem rather boring.


20. - Friends have indicated, in one way or another, that I'm more in my head than in my heart.


21. - I can't identify feelings that I vaguely sense are going on inside of me.


22. - I often ask other people what they would feel if in my personal situation (any situation), as this better helps me understand what to do.


23. - I find it useful to ponder on my feelings as much as the practical issues when setting my priorities.


24. - I use my imagination mainly for practical means, eg., like how to work out a problem or construct a useful idea or object.


25. - I often feel incompetent, awkward, uncomfortable, or occasionally physically sick in sexual situations.


26. - When involved in difficult or turbulent relationships, I sometimes develop confusing physical symptoms.


27. - I tend to rely on other people for interpreting the emotional details of personal/social events.


28. - I don’t like conversations in which more time is spent discussing emotional matters than daily activities because it detracts from my enjoyment.


29. - I often get confused about what the other person wants from a sexual relationship.


30. - People I've been in close relationships with have complained that I neglect them emotionally.


31. - I like it when someone describes the feelings they experience under circumstances similar to my own, because this helps me see what my own feelings might be.


32. - My imagination is often spontaneous, unpredictable and involuntary.


33. - When helping others I prefer to assist with physical tasks rather than offering counsel about their feelings.


34. - I have puzzling physical sensations that even friends/aquaintances/others don't understand.


35. - I get in a muddle when I try to describe how I feel about an important event.


36. - My imagination is usually not spontaneous and surprising, but rather used/employed in a more controlled fashion.


37. - I make decisions based on principles rather than gut feelings.

HOW TO HELP ALEXITHYMIA

Self-help
Alexithymia which has a biological cause may not benefit by
psychotherapy. If the neural structures involved in emotion-processing
are damaged by atrophy or injury (TBI), the process may not be
reversible. Moreover, even for those with a treatable form of
alexithymia, psychotherapy may be impractical due to travel
constraints or extravagant costs. In these cases compensatory coping
strategies can help one function as well as possible in personal and
public life. These strategies range from education to help clarify the
nature of one’s difficulties, to tailored practical ‘self-help’
strategies for better handling inter- personal relating and crises.
Along these lines the following suggestions may be useful for those
who have alexithymia:

Recognize alexithymia – don’t ignore it
If you have heard about alexithymia and suspect you have it, take time
to read more about the function or dysfunction of emotional awareness
in everyday life, and try to identify corresponding aspects of your
own experience. Most literature on emotional intelligence, and
particularly titles about Asperger’s syndrome, tend to cover this
subject. This proactive approach will prove more beneficial than
ignoring alexithymia, as it prepares the way for self-help techniques
to be targeted to those areas in which you experience setbacks. In the
long run the awareness gained will help your life to become more
manageable, adjusted and enjoyable.

Accept yourself
During the discovery process you will learn that you do not have an
inadequate personality, but that you are different in a beneficial way
and possess valuable qualities as part of that difference. Some of the
noted qualities alexithymic individuals display are loyalty,
dependability, ability to speak one’s mind, a skill for noticing
detail, exceptional memory for certain facts (such as names, dates,
schedules, routines), a desire for order and accuracy, an acute
sensitivity to physical stimuli (hearing, touch, vision and/or smell),
increased perseverance and endurance in areas of interest, and not
infrequently a prowess in certain sports or games (Attwood and Gray
1999). These traits are valued, and even desired, by those who lack
them, which knowledge can contribute to general self-acceptance as you
evaluate both the weaknesses and strengths in your character.

Practice detecting emotions
Learn to familiarize yourself with the possible signs of emotion, such
as a racing heart, feeling faint, blushing, breathlessness, body-
tension, goose-bumps, butterflies, sickness or pain in the stomach.
When such symptoms appear it will be difficult for you to distinguish
whether these signs are from emotions or physical illnesses, such is
the conundrum posed by alexithymia. But it is worth asking the
question in order to save yourself unnecessary trips to the doctor due
to misinterpretation of body states. You may be able to make a
hypothetical connection between the physical signs and current life-
events or circumstances which might have elicited the reaction in your
body.
If you have some vague sense that the symptoms may be emotional, try
to find techniques whereby you can reduce the physical effects of
these emotions in your body even if you can’t quite identify which
emotions they are. There are general ways to achieve this, such as by
reducing the quantity of your activities, slowing down your pace,
relaxing or lying down to rest, all of which may alleviate the
upsetting effects of emotional stress. On these occasions it may help
to do self-comforting activities like listening to soothing music or
preparing a favourite meal.
A second technique is to selectively change your present
cirumstances – your schedule, your present projects, or even the
company you keep with others – to see if this removes the evoking
stressors. If this does remove the stressors, your body will feel less
tense and any ill-feeling will dissipate.
Third, try injecting a new activity into your schedule and start it
immediately, preferably an enjoyable one such as a favourite sport,
hobby, watching TV or visiting a friend. This frequently succeeds in
redirecting an uncomfortable emotional state, such as depression or
sadness, replacing it with more enjoyable ones. There will of course
be times when these methods don’t work, but take heart – even non-
alexithymic people can’t always control their emotions.

Learn techniques in ‘emotional etiquette’
Because you will be mixing with non-alexithymic people much of the
time you will benefit by cultivating a keener sense of others’
emotional messages judging by their verbal and physical cues, such as
smiling and crying. If you have a vague idea of what the other person
might be feeling – even if you can only detect such broad categories
as ‘good’ and ‘bad’ or ‘happy’ and ‘sad’ – this will be a good basis
on which to craft your response. If you can recognize these general
categories of feeling, you can respond also with general ‘potted
responses’ which pass as polite and acceptable exchanges, even if you
don’t understand the fuller complexity of others’ feelings. These
versatile responses can be (a) generalised comments of concern
toward the other person’s unhappiness (e.g. ‘That’s no good’ or ‘That
must make you feel awful’) or (b) a praising response toward others’
sense of good fortune or happiness (e.g. ‘Wow! You must be happy about
that’ or ‘I’m really happy for you’). Such broad responses pass as
acceptable emotional etiquette which do not require you to look for
deeper emotional nuances.
A further useful technique in emotional etiquette, and one which
enormously benefits those with alexithymia is the so-called
‘compliment – critique - compliment’ technique. Alexithymic
individuals are noted for being direct with their stated opinions,
which to a non-alexithymic person can seem deliberately rude or
hostile. Without clear qualifiers of the emotional intent behind your
statement, non-alexithymic persons may suspect that kind words have
been deliberately withheld from statements as an act of
unfriendliness. To avoid this gross misunderstanding it pays to soften
one’s statements with a compliment before offering a blunt factual
observation. For example, where an alexithymic individual might point
out to a mathematics student ‘Your answer to that equation is
incorrect’, a more reassuring approach might go something like
‘[compliment] I like the way you set out your work, I can see you’ve
put a lot of effort into it… [critique] but on this occasion the
answer to the equation is incorrect… [compliment]but good luck on the
next question, I hope you do better’. The encouraging statements
offered here both before and after the factual critique qualifies the
emotional tone and motivation of the speaker. If no qualification is
offered, then the hearer may feel that the speaker is just being
unfriendly. Learning to use qualifiers and simple feelings responses
like those outlined above may feel somewhat automated or phony, but
they will nevertheless get you through to your old age with the least
amount of heartache to yourself from misunderstandings, and for this
reason they are worth employing.

Be wary of commonsense advice about feelings
Be wary of friends bearing commonsense advice about ‘how to get in
touch with your feelings’. Acquaintances who gain a sense of how
difficult it is for you to apprehend your feelings may suggest body-
relaxation, meditation, self-esteem affirmations, expressive
discussions, primal-screaming, and other random techniques. These
suggestions are usually intended for people with proficiency in the
normal range of feelings, and may not be suitable for alexithymics. In
fact they may even lead to confusion, frustration and physical turmoil
when your emotions become stirred and find you cannot modulate their
effects.

Create a stable routine
Without the ability to self-regulate your emotions efficiently, it is
very difficult to modulate the level of anxiety that comes with
meeting new people or facing unfamiliar circumstances. There- fore
some people with alexithymia find it helpful to maintain a stable
predictable routine to help control the sheer quantity of new
emotional information that has to be negotiated. This familiarity has
the effect of minimizing both fatigue and anxiety associated with
unfamiliar situations.

Foster co-supportive relationships
Above all it is important to have co-supportive relationships with
those who can offer guidance and strength in areas where you feel
disadvantaged. It may be that you develop a special relationship with
a non-alexithymic person, such as a friend, therapist, partner or
workmate. The advantage here is that you can integrate your
functioning with someone who can anchor you in emotional areas when
and where you need it, someone who might gently steer you away from
something when you are over-doing it to your detriment, or who can
advise you on the emotional etiquette in various situations. In turn,
you can help this person by supporting them in ways that you are
skilled at
giving, e.g. by offering them your neat reality sense and attention to
details, giving a sports massage, by helping them with their
mathematics homework or some other intellectual task, or with whatever
other talents you have. But you should be forth- right and tell the
other that you cannot function proficiently in the emotional arena,
and they are not to expect you to do so. This person should be
encouraged to seek a measure of emotional fulfillment outside of your
relationship, with others, which will help also to avoid a more
problematic co-dependent style of relationship. A girlfriend/boyfriend
would be a suitable partner for co-supportive activities because they
are frequently present, or a second choice might be a friend,
therapist or colleague (or indeed you may find several co-supportive
relationships).

Take time out to gather your thoughts
Anecdotal evidence shows that those with alexithymia are able to
process some emotional data but that it takes longer to do so because
they use different parts of their brain to do this than others.
Whereas a typical person might intuitively grasp emotional data in
milliseconds, those with alexithymia experience a delay factor lasting
anywhere from one extra second to several hours to arrive at the same
conclusion. They have to think things out in a slower, rational
manner, and to this aim ‘time-out’ rituals sometimes prove useful for
catching on to the emotional values in situations and relationships.
Reflection time usually requires a private space free of
distractions, such as a private bedroom, a study or locked bathroom,
and is best practiced a few times each day. Other relatively
distraction-free settings may be a meditation place, such as a church
or ashram, a secluded nature spot, or while doing gentle sports like
swimming, walking or gardening. The duration of time-out sessions is
up to each individual, but it is best kept short so as to avoid
practical reflection slipping into morbid rumination. Over-thinking
about past slights, failed relationships, how difficult you find life,
what people think of you, or where your life will end up in ten years
leads only to morbidity and can bring on serious depression. It is
therefore best to keep these reflective times focused on more
practical emotional matters close at hand. A second recommendation is
to terminate any time-out sessions in which only empty-headedness or
confusion manifest, as nothing productive may take place at these
times.
Overall, taking time out to gather your thoughts can improve your
grasp of the feelings, intentions and expectations of others, as well
as clarifying your own. This will greatly help your sense of clarity

and ability to make informed decisions.

Most people at one time or another have had difficulty identifying or describing how they are feeling — a temporary case of what experts callalexithymia. But for some, it can be a chronic problem, and one researcher suggests it can be remedied in part with some simple interventions.

“We know how important it is for people to empathize and be open with the people around us, because that makes someone more competent as a communicator,” said Colin Hesse, Ph.D., an assistant professor of communication at the University of Missouri.

Hesse and other communication experts are studying the ways alexithymia sufferers can ease the physical and mental costs of the disorder and succeed at relationships.

Experts estimate 8 to 10 percent of people suffer from high alexithymia. Those who have high alexithymia have trouble relating to others, as they tend to become anxious around others or avoid forming relationships.

Emotional distance often accompanies varies levels of autism, as well as post-traumatic stress disorders. Studies have shown that alexithymia has been related to eating and panic disorders, as well as substance abuse.

For individuals who have serious issues with sharing emotions, surrounding themselves with affectionate people may help improve their quality of life.

“We still need to study the best approaches, but we believe that affectionate communication ranging from hugs, touching, or even the posture taken during communication – can make a positive impact, even if it only relieves anxiety,” Hesse said.

Prior research has shown that affectionate communication can releases hormones that relieve stress.

In a paper published in the journal Personality and Individual Differences, Hesse and Kory Floyd of Arizona State University surveyed 921 people and measured shared affection, attachment levels, and the number of close relationships.

“Because there is so much gray area with alexithymia, the potential for what we learn could have benefits for people with conditions such as emotional distance and autism spectrum disorders,” Hesse said.

Source: University of Missouri