fMRI Shows How Adults With Autism Have Problems With Pronouns

AuntMinnie | Functional MRI (fMRI) has helped researchers at Carnegie Mellon University (CMU) find “diminished synchronization” between two areas of the brain to explain why high-functioning autistic adults use the wrong pronouns in their speech, according to a study in the August issue of Brain.

The ability to distinguish between “I” and “you” — called deictic shifting — appears linked to functional communication between the right anterior insula and precuneus regions of the brain, which helps a person understand the difference between one’s self and another person, as well as time, location, or various actions.

The study, led by medical student Akiko Mizuno from CMU’s Center for Cognitive Brain Imaging, found that subjects with autism were slower and less accurate in their behavioral processing of the pronouns, with slower synchronization between the right anterior insula and precuneus when answering a question that contained the pronoun “you,” compared with answering a question about the person’s view.

Deictic Shifting

Mizuno and colleagues from CMU, Duquesne University, and the University of Pittsburgh noted that shifting from one pronoun to another, depending on who the speaker is, constitutes a challenge not just for children with autism, but also for adults with high-functioning autism, particularly when referring to one’s self.

“The underlying neural basis of deictic shifting, however, is not understood, nor has the process of pronouns been studied in adults with autism,” the authors wrote.

CMU researchers enrolled 15 adults (14 males and one female) with high-functioning autism and 15 male control subjects. Both groups were matched relative to age, performance IQ, and verbal IQ.

In one task, both groups were asked to reply to a question on a card from either a first- or second-person perspective. The subject was first shown an opened book, with one object visible on the front cover and another on the back cover. The book was then closed; the subject could only see one side of the book, while a researcher could see the other side. The question asked was “What can you see now?”

The participant had to comprehend that the personal pronoun “you” referred to himself or herself, and select the object that he or she could see. The next question asked was “What can I see now?” and referred to the researcher. The participant had to comprehend that the pronoun “I” referred to the other person.

The same questions were also phrased using proper names, such as “What can John see now?” and “What can Sarah see now?” — again referring to the subject and the researcher.

Both autistic and control subjects also answered 48 questions that used a “Who” question to confirm their ability to perform deictic shifting. The questions asked who could see a particular object, the participant or the other person. The participant would reply either “I can” or “You can,” or “John can” or “Sarah can.”

MR Imaging

Functional MRI was conducted on a 3-tesla scanner (Allegra, Siemens Healthcare) at the Brain Imaging Research Center, which is jointly owned by Carnegie Mellon and the University of Pittsburgh. Brain activation was measured using blood oxygen level-dependent contrast.

The central analyses focused on the precuneus and the right anterior insula. Both functional regions of interest were defined to encompass the main clusters of activation in the group activation map for each group in the overall task versus fixation contrast.

The functional connectivity was computed (separately for each participant) as a correlation between the average time course of signal intensity of all the activated voxels of regions of interest.

Response Analysis

The analysis of fMR images showed that adults with high-functioning autism gave slower and less accurate responses compared with the control group for the items requiring deictic shifting. In addition, fMR images showed lower functional connectivity between the right anterior insula and precuneus for deictic shifting in this group.

Functional connectivity was reliably greater among controls for the tasks requiring a deictic shift compared with the other items, “suggesting that the autism group failed to show a typical adaptive change of insula-precuneus communication,” Mizuno and colleagues concluded.

In addition, activation in the right anterior insula was significantly greater for deictic shifting in the autism group only, and there was reduced connectivity between the right anterior insula and precuneus when the autism group had to go from “you” to “I,” but not when transforming “I” to “you.”

Activation in the precuneus did not change between the two tasks in the autism group, but activation was significantly lower when shifting from “you” to “I” than “I” to “you” in the control group.

“These findings indicate that deictic shifting constitutes a challenge for adults with high-functioning autism, particularly when reference to one’s self is involved, and that the functional collaboration of two critical nodes, right anterior insula and precuneus, may play a critical role for deictic shifting by supporting an attention shift between oneself and others,” the authors wrote.

Read more on AuntMinnie.com.



Kyle Henneberry, M.D.

Associate Chief Medical Officer
Dr. Kyle Henneberry is a radiologist, health-tech innovator and one of the founders and principals of Direct Radiology. A native of Spokane, Washington, he graduated with honors in Biomedical Engineering from Northwestern University, received his medical degree from Case Western Reserve University in Cleveland, Ohio, and completed radiology residency at the University of Colorado. Dr. Henneberry has United States, Europe, Australia, and New Zealand.

Jerry Lee

Chief Technology Officer

Jerry Lee has over 25 years of experience in healthcare IT. and has been with ONRAD since 2013. As the CTO, he is responsible for developing the organization’s technology strategy including IT infrastructure, application development, data analytics, cybersecurity and overall risk management. Lee’s focus is on strategic road mapping, leveraging emerging technologies and business intelligence to automate, streamline and optimize business processes. He previously worked as a senior healthcare IT consultant, where he implemented best practices, policies & procedures, and risk mitigation strategies for a variety of clients. He also previously worked as the Business Intelligence and Analytics Project Manager for a leading healthcare SaaS organization. He graduated with a B.S. from the University of California, Irvine.

Leandra Hutchinson

President, Direct Radiology

Leandra Hutchinson joined ONRAD alongside the acquisition of Direct Radiology in December 2024. Hutchison has broad experience in the healthcare industry, spending her career in healthcare technology and innovation. Prior to joining Direct Radiology in 2019, Leandra was the co-founder and Vice President of Operations of a health-tech company specializing in radiology analytics and healthcare asset management. Previously, Leandra worked in marketing, strategy, and operations roles for more than 10 years at a $7B integrated delivery system of hospitals and medical centers with more than 900 employed physicians. Hutchison earned her Bachelor’s degree from Kent State University and graduate certificate in health care policy and administration and MBA from the University of Toledo.

Ron Jackson

President, AllRads

Ron Jackson serves as President of AllRads at ONRAD, bringing over 30 years of comprehensive healthcare leadership across the provider, payer, and technology landscape. With deep expertise in radiology, he has spent more than 25 years in revenue cycle management, operations, finance, and practice management roles at leading organizations including HBOC, Per-Se Technologies, McKesson, and Zotec Partners. At ONRAD, Jackson leads day-to-day operations and strategic execution of AllRads, drawing on his cross-functional experience to drive efficiency, scalability, and growth. His 360-degree perspective of the healthcare ecosystem uniquely positions him to align organizational strategy with market dynamics in teleradiology and imaging services.

Alix Vincent, M.D.

Chief Medical Officer

Dr. Alix Vincent was one of the founding physicians at ONRAD. With over 26 years of radiology leadership experience, Dr. Vincent oversees medical staff activities, including patient safety, quality, and risk management initiatives. He manages ONRAD’s Regional Medical Directors, evaluates staff physicians, and drives clinical improvements to enhance physician alignment within the organization. Additionally, Dr. Vincent leads medical operations and played a key role in developing the company’s PACS and RIS Network capabilities. He previously served as Chief Radiologist and Chairman of the Radiology Department at Riverside Regional Medical Center. Dr. Vincent holds an M.D. in Radiology from Loma Linda University.

Lyn Mize

Chief Financial Officer

Lyn Mize serves as Chief Financial Officer at ONRAD, a role she has held since June 2022. With over two decades of experience in financial leadership, Mize has held CFO positions at various healthcare organizations, including Sunset Media Entertainment and Oncology Convergence, Inc. She also served as Vice President of Accounting at Health Choice and System Director of Accounting at Scottsdale Healthcare. Mize has a strong background in financial management, having worked with Banner Health and Greeley Medical Clinic, where she provided financial leadership for multi-specialty clinics and physician networks. Mize holds extensive expertise in driving financial performance and strategic growth across the healthcare sector and has a B.S. from DeVry University and a Masters from Grand Canyon University.

Dave Engert

President & CEO

Dave Engert started at Onrad as President and CEO in 2017. Engert is a seasoned healthcare executive with over 35 years of experience and a proven track record of leading and transforming healthcare technology organizations to drive growth and improve operational and financial performance. He previously served as President and CEO of Nighthawk Radiology, the largest teleradiology provider, and led its successful sale to vRad. Engert also held the role of President and CEO of Quality Care Solutions (QCSI), a leading provider of health insurance software, which was sold to Trizetto. Additionally, he has held leadership roles at McKesson, HBOC, and other notable companies and invested in several healthcare technology ventures. Engert holds a B.S. in Industrial Engineering from Louisiana State University.