The Cookie Theft picture included in the language evaluation of the National Institutes of Health Stroke Scale is used by more than half a million health care professionals worldwide to quickly evaluate language and other indicators of stroke. However, it reinforces stereotypical and binary gender roles and is racially and ethnically biased, placing patients and clinicians in an unpleasant position, according to a viewpoint published in the Journal of the American Medical Association Neurology. To date, it has gone unaddressed by the medical community.

Used since 1972, the Cookie Theft picture helps clinicians detect spatial and visual abnormalities and identify issues with speech and fluency. An aproned woman drying dishes but neglecting the sink overflow and her endangered children engenders misogynistic attitudes. An active boy in the process of tumbling off a high stool while toppling a cookie jar and a passive girl beneath the jar with arms outstretched (who may or may not have pushed the active boy) only serve to reinforce gender stereotypes. All appear White. The females are wearing skirts, the boy shorts, adding to othering of gendered dress.

With annual hospitalizations for stroke approaching 1 million per year in the United States, half female, half people of color, and an unknown number nonbinary, all are shown this picture considered “normal” by the medical community. Repeated exposure to this picture (often repeatedly seen by the same patients as well as by the administering clinicians) may lower self-confidence and discourage feelings of belonging and trust, according to the authors.


The authors of this viewpoint are proposing a call to action. Update the Cookie Theft picture, “with a picture description task that aligns with a goal of inclusion, reflects modern changes in societal roles, and avoids racial, ethnic, and gender stereotypes,” they stated. The authors urge that inclusion be a high priority goal, the responsibility of individual clinicians and the organization of all clinicians. They suggest other existing pictures that might be appropriate (the Picnic Scene, and Cat Rescue), or the current picture could be updated, or a new image could be created.

“The implications of gender and cultural representation and other unintended consequences of displaying biased material to hundreds of thousands of clinicians, patients, and family members around the globe each year” must be addressed, said the authors. “As clinicians, it is our responsibility to lead the way toward systemic change, and updating our clinical tools demonstrates our commitment to reduce implicit bias and to move toward a culture of diversity, equity, and inclusion.”

Disclosure: A study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

Poisson SN, Block KL, Orjuela KD. Implications of the national institutes of health stroke scale cookie theft picture-a closer look. JAMA Neurol. Published online June 13, 2022. doi:10.1001/jamaneurol.2022.1409