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Females in Neurodiversity

Image courtesy of psdgraphics.com. Female symbol.

Female (noun) – is the sex of an organism, or a part of an organism, that produces non-mobile ova (egg cells). Most female mammals, including female humans, have two X chromosomes.[1]

Okay, done with the definition. Last time, I discussed why males are more likely to have a neurodiverse condition. It’s their single X chromosome and sex hormones that makes them more susceptible to developing neurodiversity. But that doesn’t necessarily mean females are exempted in neurodiversity.

Oh?

Males may more likely to be identified and diagnosed with neurodiverse conditions, but sadly, females are more likely to be missed when diagnosing learning disabilities and developmental disorders.

Image courtesy of keepcalm-o-matic.co.uk. Wait, this proverb doesn’t mean girls are exempted from having developmental differences.

But why are females are harder to diagnose than males in neurodiversity?

One reason may be the differences in behaviors between boys and girls. We know that boys in general tend to draw more negative attention in schools. One report showed that boys represent around 85 percent of all discipline referrals. Another showed that 22 percent of boys had been formally disciplined, versus 8 percent of girls.[2] Let’s use ADHD as always as a classic example: boys with ADHD tend to show more hyperactivity, impulsivity and physical aggression than girls with ADHD. That behavior makes them stand out from the other boys. Meanwhile, girls with ADHD are more likely to show a different set of symptoms and side effects. These include anxiety, depression, constant talking, daydreaming and low self-esteem. But their behavior appears more typical of how other girls behave.[2]

In short, males and females in neurodiversity present different symptoms.

(C) Cartoon Network. Er, not the Powerpuff Girls. But basically, sugar, spice, and everything nice don’t make girls immune from neurodiversity.

Another thing that makes it difficult to diagnose females in neurodiversity is this: the female sex itself. In my previous post, one study showed that the double X chromosome seems to be a protective barrier for females against genetic, chromosomal, or environmental hazards. For example when having chromosomal defects, females are almost always unaffected, thanks to their double X chromosome. While one X chromosome is defective, the other X chromosome is usually normal, and that saves the female from developing chromosomal defects.

“When you look at the X chromosome, there are 1,500 genes and 5 percent are important to brain development…imagine you’re a male, any mutation that even makes the protein produced a little weaker or less efficient, now you’re stuck with that,” researcher Evan Eichler, a professor of genome sciences at the University of Washington School of Medicine, said. “The female, because she has two X chromosomes, chances are if she has a defective mutation on one of those genes, she can compensate because she has one from the other parent.”[3]

“The female, because she has two X chromosomes, chances are if she has a defective mutation on one of those genes, she can compensate because she has one from the other parent.”

It’s like “the heir and the spare” sort of thing.

Another study also confirmed that females at better in overcoming effects of genetic mutations that makes them less likely to manifest symptoms of neurodiversity. The researchers in Switzerland theorized that women are better able to overcome genetic mutations, compared to men. Despite the fact that females had more mutations – and larger mutations – they were less likely to develop diagnosable neurodevelopmental problems.[3]

“Girls tolerate neurodevelopmental mutations more than boys do. This is really what the study shows,” said study author Sebastien Jacquemont, an assistant professor of genetic medicine at the University Hospital of Lausanne, in Switzerland.[4]

Image courtesy of imgarcade.com. Wait, girls, don’t celebrate yet. More mutations are needed for girls to develop learning disabilities and developmental disorders.

This so-called female protective model lessens girls to have neurodivergent conditions, but more genetic mutations are needed for a female to develop such conditions.

Reason: anatomical. It is based on brain-imaging studies which suggest differences between the patterns of internal connection in male and female brains. Male brains have stronger local connections, and weaker long-range ones, than do female brains. That is similar to a difference seen between the brains of autistic people and of those who are not. The suggestion here is that the male-type connection pattern is somehow more vulnerable to disruption by the factors which trigger autism and other cognitive problems.[5]

Let’s see how male brains differ from female brains:

Image courtesy of clearmirrorhealing.wordpress.com. No, not that sort of brain… although this is true ^_^

Image courtesy of The Guardian. Male brain neural map.

The male brain pattern. Now, let’s look at the female brain.

Image courtesy of The Guardian. Female brain neural map.

Ah, it’s complicated. But more connections are there in females’ brains.

Another reason: females’ compensation to hide neurodiverse symptoms. For example, in autism spectrum disorder (ASD), while young males are “obvious” in their symptoms, young females “mask” their symptoms by compensating their behavior. Because ASD causes “social blindness,” kids with ASD don’t know how to interact with other people. While boys are reluctant to this, girls are more aware of their difference. To compensate for their difference, girls “shapeshift” in order to be similar to neurotypical girls to have interaction.

Shapeshift?

Shapeshifting is a term coined by The Curly Hair Project.[6] It is the ability of an ASD female to copy the social graces of a neurotypical in order to bond with other people.[6] The process goes like this:

Observe –> analyze –> understand –> react[6]

First, the ASD female observes how neurotypical girls bond (making eye contact, grooming, updates about fashion, romcoms, and boys, observing facial expression, body language, gesture, tone of voice, etc.). Then, the ASD female analyzes these observations and then understands why such gesture is done, i.e. flirting is done to see whether a man is interested to her or not, why empathizing a friend is helpful, etc. From there, the ASD female shift into that what the other person needs us to be[6] to interact with other people.

In summary, shapeshifting in ASD is one way of females compensating for their neurodiversity, comparable to an actress rehearsing her script.

(C) The Curly Hair Project. The Shapeshifting Process in ASD.

(C) The Curly Hair Project.
The Shapeshifting Process in ASD.

To better illustrate shapeshifting in ASD females, let’s use the little mermaid as an example. Mermaid/nymph tales (The Little Mermaid, Undine, Rusalka (Dvorak’s opera), Selkie, etc.) involve mermaids falling in love with human princes and desiring to be human as well. To be human, they exchange their voice (communication) for legs, which makes them human, but mute. Unfortunately, these tales have a sad ending. Except for the Disney version of Little Mermaid where Ariel lives happily ever after with Prince Eric, most mermaids fail to win the prince’s love and end up either dead or damned.

In fact, one article in Patheos described how mermaids are similar to ASD females: …these tales—three faces of one story—involve water creatures shape shifting into human form, rather than humans transforming into animal form. What a curious emotional stunting we see on the part of humans—in these stories, we do not return love, we do not recognize love, we betray love, we mistake coercion for love. In the little mermaid’s case, there is an inability to communicate…the symbolic loss of her tongue could equally describe the inability of the prince to understand or register her voice.[7]
Much like the ASD female’s shapeshifting effort. Though she is successful into morphing into a neurotypical girl, her true self is lost like the mermaid’s loss of tail and voice just to be liked by other people, regardless whether people will actually like her or not, and this is double whammy when people don’t like the ASD female despite her shapeshifting (I’m totally related to this experience, though…)
And the author concluded: “These stories of the waterfolk who occasionally rise to the surface and mingle with us remind me to stay alert for the variety of intelligences that nudge and stretch our concept of what it is to be human, to be normal. What would it be if we reframed mental difference, psychological outliers, as filled with potential? Gifted, rather than different, strange, wrong, needing to be fixed?”

(C) Disney. The little mermaid is autistic? Shapeshifting in ASD females are already illustrated by mermaid tales when falling in love with humans.

“These stories of the waterfolk who occasionally rise to the surface and mingle with us remind me to stay alert for the variety of intelligences that nudge and stretch our concept of what it is to be human, to be normal. What would it be if we reframed mental difference, psychological outliers, as filled with potential? Gifted, rather than different, strange, wrong, needing to be fixed?”

The flip side: compensating for neurodiversity is mentally exhausting. Unlike neurotypical girls who interact intuitively, neurodivergent females use their conscious effort to compensate for their symptoms. This result in mental drain and can cause anxiety, depression, obsessive-compulsive disorder, eating disorders, and phobias. Not good because psychiatrists usually first detect these mood disorders instead of the developmental/learning disability itself.

What it is like for a female in neurodiversity?

While most neurodiverse conditions’ symptoms mainly apply to males, females present different symptoms aside from showing different behavior, having double X chromosomes, and conscious masking behaviors. And the worse part is that female neurodiverse symptoms are considered ideal in society thanks to the sugar, spice, and everything nice thing, which makes it harder for specialists to diagnose females.

(C) Wikipedia. Mary Pickford portraying an ingenue, which has the ideal behavior of girls and women in society ( which makes females in neurodiversity very ideal, ignoring their true symptoms).

Except for hyperactive or tomboyish females in neurodiversity, most of them fit into the “ingenue” (an innocent or unsophisticated young woman) category. Very ideal in society, but ignoring their true symptoms.

Image courtesy of Slideshare. Females in neurodiversity can be considered females with hidden disabilities.

Now, the bottom line: This make females in neurodiversity at more risk of all the hazards she can face thanks to her hidden disability. Risks include development of mood and eating disorders, educational underachievement (or overachievement, which is bad either as it results in more stress), unemployment or underemployment, social isolation, and/or relationship difficulties and becoming domestic violence or rape victims, and these are more common to females with undiagnosed ADHD and/or autism.

This is no joke. While girls’ niceness can seem lovely to the eyes of the authorities, they outgrow these when reaching puberty. And after puberty, the fall into the slippery slope of misery, wondering why they are weird or something and/or disorganized, making neurodiverse symptoms worse and damaging to their well-being.

An article from the Atlantic describes how females with ADHD suffer: Further, while a decrease in symptoms at puberty is common for boys, the opposite is true for girls, whose symptoms intensify as estrogen increases in their system, thus complicating the general perception that ADHD is resolved by puberty. One of the criteria for ADHD long held by the Diagnostic and Statistical Manual, published by the American Psychiatric Association, is that symptoms appear by age 7. While this age is expected to change to 12 in the new DSM-V, symptoms may not emerge until college for many girls, when the organizing structure of home life—parents, rules, chores, and daily, mandatory school—is eliminated, and as estrogen levels increase.[8]

In “The Secret Lives of Girls with ADHD,” published in the December 2012 issue of Attention, Dr. Littman investigates the emotional cost of high-IQ girls with ADHD, particularly for those undiagnosed. Confused and ashamed by their struggles, girls will internalize their inability to meet social expectations. Sari Solden, a therapist and author of Women and Attention Deficit Disorder, says, “For a long time, these girls see their trouble prioritizing, organizing, coordinating, and paying attention as character flaws. No one told them it’s neurobiological.”[8]

As for females with ASD, they experience the same difficulties ADHD females, not being socially attuned, having psychological problems due to their neurobiology plus combining with common problems neurotypical females face.

According to SEN Magazine in their article about autism in girls: It is not until puberty that girls’ social difficulties become more obvious, particularly as they enter secondary school when they can become the subject of bullying or can be generally marginalised and perceived as strange. Unlike boys, they become withdrawn, depressed and quiet, rather than aggressive.

Profound anxieties may be demonstrated in altered behaviours, lower grades at school, poor sleep patterns, low mood/depression and obsessive behaviour.

Research from 2011 found that many women who were later diagnosed as being on the autistic spectrum initially were thought to have learning difficulties, personality disorders, obsessive compulsive disorder or eating disorders (Rivet and Matson, 2011). This differential diagnosis could be related to lack of awareness of how ASD present in females.[9]

In the book ‘Asperger’s Syndrome for Dummies’ (Gomez de la Cuesta & Mason 2010), the authors touch on this issue and describe different ‘types’ of women on the autism spectrum. At work, women experience ‘a glass ceiling that is double glazed’ according to the authors. Women experience the same difficulties as other women, plus the difficulties experienced by women on the autism spectrum.[10]

Undiagnosed learning disabilities (LDs) can be a slap on the face too. Girls with LDs tend to overcompensate their difficulty, which may or may not yield good results, making them at risk for verbal and emotional discrimination, i.e. teachers/professors and employers may call her stupid/dumb or irresponsible, making her prone to unemployment.

Image courtesy of dual diagnosis.org. Depression is usually the common feature of women in neurodiversity.

Final note: While LDs, ADHD, and ASD are now beginning to be recognized by the commonfolk, their presentation to the female population must not be ignored and awareness of these must be continued or pushed further. Remember, females in neurodiversity are still females and humans with the same needs as the rest of us: understanding and acceptance.

Reference

  1. http://en.wikipedia.org/wiki/Female
  2. https://www.understood.org/en/learning-attention-issues/getting-started/what-you-need-to-know/do-boys-have-learning-and-attention-issues-more-often-than-girls
  3. http://www.foxnews.com/health/2014/02/27/study-reveals-why-autism-is-more-common-in-males
  4. http://consumer.healthday.com/cognitive-health-information-26/autism-news-51/gene-study-offers-clues-to-why-autism-strikes-more-males-685295.html
  5. http://www.economist.com/news/science-and-technology/21597877-women-have-fewer-cognitive-disorders-men-do-because-their-bodies-are-better
  6. http://thegirlwiththecurlyhair.co.uk/blog/2014/05/17/asd-females-shapeshifting/
  7. http://www.patheos.com/blogs/sermonsfromthemound/2014/07/shapeshifting-autism-and-the-little-mermaid/#sthash.524lMZc7.dpuf
  8. http://www.theatlantic.com/health/archive/2013/04/adhd-is-different-for-women/381158/
  9. https://www.senmagazine.co.uk/articles/articles/senarticles/is-autism-different-for-girls
  10. http://www.autism.org.uk/about-autism/autism-an-introduction/gender-and-autism/women-and-girls-on-the-autism-spectrum.aspx

Further Reading:

  1. http://www.theguardian.com/society/2015/feb/10/victims-domestic-violence-abuse-women-learning-disabilities
  2. http://www.theatlantic.com/health/archive/2013/04/adhd-is-different-for-women/381158/
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3

Specific Language Impairment

Language is the blood of the soul into which thoughts run and out of which they grow.
– Oliver Wendell Holmes

We use language to share ideas and feelings to each other. In fact, we humans speak the most specialized and complicated language in the animal kingdom. However, not all of us can speak a language the way most people do.

Does this mean fluency?

No. It is more complicated than simple fluency. Language comprises of phonology (pronunciation), syntax (word order), semantics (meaning of words/phrases in a language), prosody (the rhythmic and intonational aspect of language[1]), pragmatics (what words mean in particular situations[1]), sarcasm (the use of words that mean the opposite of what you really want to say especially in order to insult someone, to show irritation, or to be funny[1]), humor, and body language. Not all of us can readily understand, interpret, and express language using all of these. The difficulties in language acquisition and usage are grouped as language disorders. The specific difficulty in receiving and sending language is called specific language impairment.

What is Specific Language Impairment?

Specific language impairment (SLI) is a type of communication/language disorder where a person affected with it cannot comprehend and express language. It is characterized by difficulty with language that is not caused by known neurological, sensory, intellectual, or emotional deficit. It can affect the development of vocabulary, grammar, and discourse skills, with evidence that certain morphemes may be especially difficult to acquire (including past tense, copula be, third person singular). Children with SLI may be intelligent and healthy in all regards except in the difficulty they have with language. They may in fact be extraordinarily bright and have high nonverbal IQs.[2]

Children with SLI are often called ‘late-talkers’ as they typically start to speak later than the typically developing children. While kids learn to talk simple words by 1 year, kids with SLI do the same in 3 years, making them delayed by 2 years against typocal children. Usually, parents and teachers see them as lazy, awkward, or not trying enough; actually, kids with SLI are eager to learn and talk but find it hard to ‘find the right words’ and express their ideas.

SLI has subtypes:

Expressive language disorder – also known as developmental verbal dyspraxia (DVD), where language expression is late and incomplete despite comprehension of language.[3]

Receptive language disorder – here, the child’s most obvious problems are a tendency to speak in short, simplified sentences, with omission of some grammatical features, such as past tense -ed.[3][4] Comprehension of language is affected.

Mixed receptive/expressive language disorder -a combination of both receptive and expressive language disorders.

Phonologic programming deficit syndrome – The child speaks in long but poorly intelligible utterances, producing what sounds like jargon.[3]

Lexical deficit disorder – The child has word finding problems and difficulty putting ideas into words. There is poor comprehension for connected speech.[3]

Pragmatic language impairment – The child speaks in fluent and well-formed utterances with adequate articulation; content of language is unusual; comprehension may be over-literal; language use is odd; the child may chatter incessantly, be poor at turn-taking in conversation and maintaining a topic.[3] Also known as social communication disorder or social (pragmatic) language disorder.

SLI is considered to be autism’s older brother, dyslexia’s younger brother, and dyspraxia’s twin because of its similiarities with these; however, SLI is one of the most difficult to recognize among learning disabilities. In fact, SLI remains very much a “hidden disability” within the community – poorly understood and rarely discussed.[5]

What causes SLI?

Genetics is one of the causes of SLI. One specific gene mutated for SLI is called CNTNAP2 gene (pronounced “catnap”) on chromosome 7q.[5]

But like autism, it’s unlikely that just one gene causes the majority of SLI cases. Rather, it’s probably the case that multiple gene variants that, when combined (and perhaps in conjunction with environmental factors), cause language difficulties.[5]

The effects of genes involved with SLI are likely to cause a different pattern of brain development. The enduring mystery of SLI is that no clear brain abnormality has been identified as a cause of language difficulties.[5]

How common is SLI?

SLI is so common it affects up to one child in every class and is as common as dyslexia and more common than autism but is barely heard of by the general public.[6]

What are the symptoms of SLI?

People with SLI have the following symptoms[7]:

Language:

Noticeably behind other students in speech and/or language skills development
May have a learning disability (difficulties with reading or written language) with average intelligence
Improper use of words and their meanings
Inability to express ideas
Inappropriate use of grammar when talking or writing
Inability to follow directions
Difficulties in understanding and/or using words in context, both verbally and nonverbally
May hear or see a word but not be able to understand its meaning
May have trouble getting others to understand what they are trying to communicate
Has difficulty remembering and using specific words during conversation, or when answering a question
Asks questions and/or responds to questions inappropriately
Has difficulty discriminating likenesses and differences
Has difficulty breaking words into sounds and syllable
Has difficulty with concepts of time, space, quantity, size, and measurement
Has difficulty understanding and using complex sentences
Has problems understanding rules and patterns for word and sentence formation
Cannot identify pronouns
Cannot retell the events in a story in order
Cannot make predictions, make judgments, draw conclusions
Difficulties with figurative language (such as alliteration, similes, metaphors, personification, and idioms)
Cannot give clear directions
Cannot summarize essential details from hearing or reading a passage, nor distinguish relevant from irrelevant information
Has difficulty understanding and solving math word problems (one or multi-step)
Will not initiate conversations
Has difficulty reading what others communicate through facial expressions and body language
Repeats what is said or what is read, vocally or subvocally (under breath)
Uses gestures when talking or in place of talking
Is slow to respond during verbal interaction or following verbal cues
Cannot identify or use different language in written work (expository, descriptive or narrative)
Cannot write an organized paragraph

Speech:

Noticeably behind other students in speech and/or language skills development
Trouble forming sounds (called articulation or phonological disorders)
Difficulties with the pitch, volume, or quality of the voice
May display stuttering (dysfluency), an interruption in the flow of speech
Omits or substitutes sounds when pronouncing words
May have trouble getting others to understand what they are trying to say
May have trouble with the way their voice sounds
Is echolalic (repeats speech)
Does not use appropriate speaking volume (too loud or too soft)
May have breathy, harsh, husky or monotone voice
Continually sounds congested
Sounds nasal and voice may have a “whining” quality
Has abnormal rhythm or rate of speech
Frequently prolongs or repeats sounds, words, phrases and/or sentences during speech
Has unintelligible (cannot be understood) or indistinct speech

Academics and Behavior:

Overall academic achievement may be lower than expected
Word knowledge may be below expectancy
Word substitutions may occur frequently in reading and writing (when copying)
Hesitates or refuses to participate in activities where speaking is required
Is inattentive and has difficulty with concentration
May not initiate or maintain eye contact
May become easily frustrated
Has difficulty following directions
Must be “shown” what to do
Has trouble understanding information from what is seen, heard or felt
May be embarrassed by speech, regardless of age
Acts impulsively, and may respond before instructions are given out
May isolate themselves from social situations

Physical:

May be conditions in the student’s medical/developmental history, such as cleft lip and/or palate, cerebral palsy, muscular dystrophy, brain injury or disorder, aphasia, hearing loss, ear surgery, facial abnormalities, or congenital (present at birth) disorders
Has frequent allergy problems or colds
Has oral muscular coordination slower than normal
Displays clumsiness or seems to be uncoordinated

How is SLI diagnosed?

SLI is defined purely in behavioural terms: there is no biological test for SLI. There are three points that need to be met for a diagnosis of SLI:

The child has language difficulties that interfere with daily life or academic progress
Other causes are excluded: the problems cannot be explained in terms of hearing loss, general developmental delay, autism, or physical difficulty in speaking
Performance on a standardized language test (see Assessment, below) is significantly below age level.[3]

EpiSLI criterion is also used, based on five composite scores representing performance in three domains of language (vocabulary, grammar, and narration) and two modalities (comprehension and production). Children scoring in the lowest 10% on two or more composite scores are identified as having language disorder.[3][8]

Furthermore, specific language impairment does not involve global developmental delays; children with SLI function within the typical range in non-linguistic areas, such as nonverbal social interaction, play, and self-help skills (e.g., feeding and dressing themselves). Children with autism spectrum disorders have core impairments in social interaction and communication, including both nonverbal and verbal skills, as well as certain characteristic behaviors (e.g., repetitive movements, lack of pretend play, and inflexible adherence to routines) that are not found in youngsters with SLI.[9]

How is SLI managed?

Intervention is usually carried out by speech and language therapists, who use a wide range of techniques to stimulate language learning.[3] The intervention is interwoven into natural episodes of communication, and the therapist builds on the child’s utterances, rather than dictating what will be talked about. In addition, there has been a move away from a focus solely on grammar and phonology toward interventions that develop children’s social use of language, often working in small groups that may include typically developing as well as language-impaired peers.[3][10]

Fast ForWord[11] is also used as a therapy for children with SLI. Fast ForWord is a family of educational software products intended to enhance cognitive skills of children, especially focused on developing “phonological awareness.”[11][12] Here, Fast ForWord uses computerized exercises in which children identify computer-generated speech sounds (although the latest versions of the product apparently includes others kinds of computerized training as well). In the speech-sound drills, the training program starts off with sounds that have been altered by computer processing. These processed sounds preserve the frequency content of normal speech sounds, but are slowed down and have artificially exaggerated differences. These changes make the task easier for children with slower than normal temporal processing, but paradoxically are more difficult to discriminate for temporal processing normals. As the subject progresses, these differences are reduced to make the games more challenging.[11]

What happens if SLI is not managed?

Complications arise when SLI is not identified and intervened. Primarily, a child’s academic and social life will be adversely affected. Children with SLI are less likely to complete secondary school, and are more likely to experience long periods of unemployment during adulthood. What’s more, individuals with SLI have greater difficulties forming close friendships and romantic relationships.[5]

The impact on mental health is significant, and adults with SLI are at a disturbingly high risk (around 50%) for depressive and anxiety disorders.[5]

Early identification and intervention is very important so as to address the very specific problems children with SLI.

And remember, if you see a person who talks erratically, that doesn’t necessarily mean he or she is dumb, liar, or immature. Maybe he or she has specific language impairment.

References:
1. Merriam-Webster Dictionary 2015.
2. http://www.asha.org/Publications/leader/2001/010626/sli.htm
3. http://en.m.wikipedia.org/wiki/Specific_language_impairment
4. Leonard, Laurence B. (1998). Children with specific language impairment. Cambridge, Mass: The MIT Press. ISBN 0-585-27859-8. OCLC 45728290.
5. http://theconversation.com/autisms-hidden-older-brother-specific-language-impairment-6295
6. http://www.huffingtonpost.co.uk/claire-mitchell/specific-language-impairm_b_1576898.html
7. http://www.do2learn.com/disabilities/CharacteristicsAndStrategies/SpeechLanguageImpairment_Characteristics.html
8. Tomblin JB, Records NL, Zhang X (December 1996). “A system for the diagnosis of specific language impairment in kindergarten children”. J Speech Hear Res 39 (6): 1284–94. doi:10.1044/jshr.3906.1284. PMID 8959613.
9. http://www.gemmlearning.com/can-help/speech-language/delay-info/specific-language-impairment/
10. Gallagher, T. (1996). Social-interactional approaches to child language intervention. In J. Beitchman, N. J. Cohen, M. M. Konstantareas & R. Tannock (Eds.), Language, Learning and Behavior Disorders: Developmental, Biological and Clinical Perspectives (pp. 493–514). New York: Cambridge University Press.
11. http://en.m.wikipedia.org/wiki/Fast_Forword
12. Begley, S.; Check, E. (1 Jan 2000). “Rewiring your gray matter”. Newsweek: 63. Retrieved 2010-02-05.