The Peter Attia Drive - #330 – Autism, ADHD, and Anxiety： Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children ｜ Trenna Sutcliffe, M.D.

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

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00:00:53.200 of the subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.020 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Dr. Trenna

00:01:06.280 Sutcliffe. Trenna is a developmental behavioral pediatrician and the founder and medical director

00:01:12.120 of the Sutcliffe Clinic in the Bay Area, which partners with patients and their families to

00:01:16.740 evaluate and provide supportive care for children dealing with issues such as behavioral changes,

00:01:21.420 developmental differences, and school struggles. In my conversation with Trenna, we explore her

00:01:26.020 journey into developmental and behavioral pediatrics. In fact, she was the first person

00:01:31.140 to be practicing under this designation at Stanford when she arrived about 20 years ago. This includes

00:01:37.260 her background in genetics, pediatric neurology, and her current work in leading multidisciplinary

00:01:41.660 teams around the care of children with autism, ADHD, and anxiety. We spoke about the diagnostic

00:01:47.740 processes for autism, ADHD, and anxiety, which she calls the three A's, discussing how these

00:01:52.760 behavioral diagnoses are made based on clinical traits and the criteria depending on the age of

00:01:57.120 a child. We focus on the overlap between the three A's and how comorbidities are common in children

00:02:02.600 with each of these conditions. Trenna emphasizes the importance of a personalized treatment plan to

00:02:07.680 consider the whole child, including their environment at home and school. We talk about the changing

00:02:12.740 diagnostic criteria for autism between the DSM-4 and the DSM-5 and what some of the drivers might be

00:02:20.640 for the increase in the prevalence of autism today. This is a very hotly discussed topic. Trenna provides

00:02:27.500 a very thorough discussion of what the factors are that may be contributing to this. We discuss the

00:02:33.820 various therapies, including applied behavioral analysis, or ABA for autism, behavioral interventions,

00:02:39.740 and parental training for ADHD. We cover pharmacologic options, particularly for ADHD and anxiety,

00:02:46.720 including the use of stimulants, non-stimulants, and SSRIs. Trenna explains how these medications are

00:02:52.060 used alongside behavioral interventions to help children manage symptoms and improve their daily

00:02:56.840 lives. And we talk about the challenges families face in accessing care, particularly outside of major

00:03:02.080 urban areas, and the importance of bridging healthcare and education to create a more holistic

00:03:06.340 approach to support children with these developmental conditions. So without further delay, please enjoy

00:03:11.840 my conversation with Dr. Trenna Sutcliffe. Well, Trenna, thank you so much for coming all the way out to

00:03:21.880 Austin. Really nice to meet with you in person. I've heard a lot of things about you from various

00:03:26.820 colleagues in the Bay Area. And frankly, this is just a topic that I think a lot of people are interested

00:03:32.780 in. Obviously, many of them parents, but I just think people in general are kind of interested.

00:03:37.320 And so maybe just before we jump into it, let's spend just a couple of minutes on your background

00:03:41.760 so people understand who you are and why I wanted to spend so much time with you. So you trained in

00:03:47.860 pediatrics, developmental and behavioral. Well, let me not try to summarize what you've done. Tell me what

00:03:53.500 you've done. Okay. Well, initially I did an undergrad and master's degree in genetics and then went on to

00:04:00.480 medical school. After medical school, I went on and did a residency in pediatrics, but ultimately

00:04:07.560 wanted to do developmental behavioral pediatrics for numerous reasons because it just was a really

00:04:13.200 good fit with my interests and passions. So I did actually a year in pediatric neurology and then a

00:04:20.340 full fellowship in developmental behavioral pediatrics before moving to California.

00:04:24.660 Yeah. Your interests today primarily revolve around behavioral therapy for three things that

00:04:32.300 we're going to spend quite a bit of time talking about. I won't commit to the order yet because

00:04:35.960 that'll come out of our discussion, but somewhere along the way, we're going to talk about autism.

00:04:39.780 We're going to talk about ADHD and we're going to talk about anxiety. So coming at this through the

00:04:45.480 lens of what you do today, which is running a really large, successful, multidisciplinary clinic.

00:04:50.980 I assume this is just for children. So this is up to 18 years old, basically is your patient

00:04:55.660 population. Correct. Let's start by just getting some of the diagnostic criteria straight. I think

00:05:01.820 that in general, most people listening to us have a gestalt for what each of those things are,

00:05:06.940 but I think it would be helpful to maybe understand clinically how you look at each of those. So let's

00:05:12.280 start with anxiety. How I look at it clinically. Yeah. And how is it defined? How clear are the

00:05:17.900 diagnostic criteria? What does the DSM-5 say about it? And how does a practicing clinician

00:05:23.920 use that or maybe modify that in the way that they try to come up with a diagnosis?

00:05:29.220 So with all of these diagnoses, anxiety, ADHD, autism, they're behavioral clinical diagnoses. So it's

00:05:37.480 based on checklists of a number of traits and characteristics. Now you need to be working with

00:05:44.460 a clinician, a physician who has enough experience diagnosing these conditions, trained in these

00:05:51.880 conditions. But essentially that person needs to be an expert on what the clinical picture looks like

00:05:58.320 because there's no biomarkers for any of these conditions. That's the key thing. There are no

00:06:03.360 blood tests or no brain scans to say who has anxiety, who has ADHD, who has autism. I have families

00:06:10.900 come to me all the time and I explain to them, I have these clinical boxes and labels and diagnoses

00:06:16.700 in my clinic. And these boxes and labels are man-made. We create these lists of criteria,

00:06:23.680 but neurobiology in the brain is much more complex than these boxes. So the key thing is to have a

00:06:31.980 clinician who looks at the, and for me, a child, and looking at their traits at home, at school,

00:06:38.480 in multiple environments, collecting data through talking to parents' history, getting information

00:06:45.200 from people other than the parents. So that's using rating forms or talking to teachers and therapists.

00:06:51.620 Ideally, we get to see the child in their real-life environment. So maybe even observing them in a

00:06:57.680 real-life place like school, and then doing assessment in the clinic to collect information about them.

00:07:03.600 And with that, that clinician decides whether or not they meet diagnostic criteria, a list of traits

00:07:11.440 or characteristics described in a book called the DSM. And then we decide whether that child meets that

00:07:16.500 criteria. But one of the key things is about whether or not those traits are creating impairment. And

00:07:22.760 that's a key criteria for any of these diagnoses. For example, anxiety. We all have feelings of anxiety.

00:07:30.640 Anxiety is actually a very appropriate, normal feeling that we should all have. But it's all about

00:07:37.760 how much impairment is it creating? How does it impact function and impact someone doing their job?

00:07:45.240 And for a child, their job is to learn and go to school, make friends, practice communicating and

00:07:53.300 interacting with other peers, and be a positive contributor in their community, which is school.

00:07:58.260 So it's about how these traits impact their function in that job.

00:08:03.120 What would you say is the youngest age that each of those could be diagnosed? And I do want to talk

00:08:09.820 a little bit about what the layers of diagnostic criteria are. But just starting at the first

00:08:15.220 question, which is, if a parent says, hey, I think my child has such and such, I really want to get a

00:08:21.140 workup. Is there an age beneath which you would say this might not be a good use of time and energy?

00:08:25.700 So for autism, although the typical age for diagnosis is more like three or four,

00:08:32.080 we can confidently make that diagnosis as young as 18 months of age. And I'll be honest,

00:08:37.720 in the last 20 years, there's been one or two cases where I've made it at 15 months of age,

00:08:42.320 because it was very significant and obvious. Most often at that young age, we do wait a few more

00:08:48.800 months to watch how the child develops because kids are a moving target. But with autism, it can

00:08:55.700 be 18 months, two years of age, although half of the cases of autism are diagnosed over six.

00:09:01.420 With ADHD, you can make a diagnosis as young as four years of age. But again, I'll just tell you from

00:09:08.000 my clinical experience, I rarely jump onto the diagnosis with a four or five-year-old because

00:09:15.160 they're still a moving target. Although I may start interventions, behavioral interventions and

00:09:20.260 parenting support, but there are a lot of four-year-olds who are pretty busy. So I generally

00:09:24.340 wait closer to school age, although technically you can make it as young as four.

00:09:28.500 So that would be for most kids, when you say school, you don't mean preschool,

00:09:31.220 you mean actual kindergarten, five to six.

00:09:33.140 Five to six, I think. A lot of people will wait till five or six to really see how that child is

00:09:38.540 evolving. Although technically you could make it younger. And then with anxiety,

00:09:42.440 there's separation anxiety. There's something called selective mutism in young kids, in preschoolers.

00:09:49.240 So anxiety, there's many different types of anxiety, but there's definitely anxiety conditions

00:09:53.320 in preschoolers. Let's talk a little bit more about that. I don't know much about anxiety,

00:09:57.720 and I'm guessing most people listening have a sort of hand-waving sense of what it means. But

00:10:02.720 you said separation anxiety as an example. Anyone who's been a parent can appreciate moments of that.

00:10:08.720 99% sure our puppy has separation anxiety. What are some of the other types of anxiety,

00:10:14.220 and how do you look to spot those in kids?

00:10:17.200 So again, just to emphasize, anxiety is actually a normal emotion that we should all have.

00:10:21.220 So it's all about whether it's created enough impairment. So in the anxiety bucket,

00:10:25.620 there's multiple different types. So someone may have generalized anxiety, where that's exactly it.

00:10:31.660 It's generalized. It's seen in multiple places as pretty pervasive. People can have specific phobias

00:10:36.900 towards dogs or spiders or other things. I mentioned separation anxiety. So that is a

00:10:42.280 condition. And again, yes, many toddlers have separation anxiety. That's very normal. It's about

00:10:47.980 how severe and significant the anxiety is, and how pervasive it is, and whether it is impacting

00:10:55.540 function. So when it's impacting the ability for a child to go to childcare or preschool,

00:11:00.760 then it's something we need to help. Other types of anxiety, there's something called selective

00:11:05.140 mutism. Children who are able to speak very well and speak well at home or with familiar adults,

00:11:12.780 but do not speak and are mute outside that familiar environment. There's also obsessive-compulsive

00:11:19.180 disorder, where people have obsessive thoughts or compulsive behaviors. So there's many types of

00:11:25.760 anxiety conditions out there, and children have these.

00:11:29.800 You've reiterated it twice now, which tells me how important it is. It really has to come down to

00:11:34.060 this impairment thing. All of us could probably read through the DSM-5 and place ourselves in each

00:11:39.500 of these diagnostic buckets. I know I can. I've done that exercise, and it turns out I could make

00:11:44.240 the case I have everything. But the truth of it is, what I try to ask is, which is maladaptive?

00:11:48.800 Which is mostly giving me the negative response that is impacting relationships or work or these

00:11:54.020 other things. I like that framework for kids, because if you think to yourself, oh, my kid has ADHD,

00:11:59.220 ADHD, but they're doing well in school. They're progressing in reading, writing, arithmetic.

00:12:04.420 They enjoy playing sports. Yeah, maybe they're a little bit more rambunctious, but they have

00:12:09.160 friends. How would you help a parent sort of navigate that? If they came to you and said,

00:12:13.960 I think my son or my daughter has ADHD, what are kind of the impairment-style questions you would be

00:12:18.900 asking to paint the contours of this condition, even if you acknowledge that that kid's got a lot of

00:12:25.200 energy? Those are great questions, because it is definitely a spectrum. There's a bell curve.

00:12:29.820 We're all on a bell curve. For all of these diagnoses, there's a bell curve. And so it's

00:12:33.900 when does it become leaving the average range, the typical profile, and over into what we call a

00:12:40.600 disorder? And actually, I don't like to use the word disorder for these conditions either,

00:12:43.980 because I think they're just learning differences and thinking differences as well. But when does it

00:12:48.200 become a disorder? So questions around impairment. So for me, one of the number one things I talk

00:12:54.220 about with families is self-esteem. How is it impacting that child's self-concept, how they

00:12:59.380 see themselves? How is it impacting their relationships with peers? That's another key

00:13:04.760 one. So does it impact social interactions? Does it impact how they connect with peers? Does it impact

00:13:12.480 the feedback they're getting from peers? How does it impact their ability to learn and access

00:13:18.320 learning opportunities at school or on the playground? So are these traits impacting their

00:13:25.580 ability to fully engage in learning, be successful, show their potential? The self-esteem thing is very

00:13:32.180 important to me, though. So for a child who has a biologic condition, these are all biologic. There's

00:13:40.380 neurochemicals, there's genetics involved. These are biologic conditions. And for a child to have a

00:13:46.300 biologic condition and be in class and then feel bad because they are worried they're not doing

00:13:54.240 well enough and they're getting a lot of negative feedback from teachers and peers. Not because those

00:14:00.460 people are trying to be mean or negative, but they have to constantly remind that child because that

00:14:06.520 child is forgetting things, losing things, forgot to put their name on the piece of paper,

00:14:11.020 completely off task. Keeps losing things.

00:14:13.400 Losing, yeah. So it's losing, forgetting. It's not completing tasks. It's not sustaining attention

00:14:19.520 in a conversation. It's actually avoiding tasks that require a lot of sustained attention.

00:14:27.040 So there's a lot of these traits where it's impacting this child's ability to be successful

00:14:32.740 day-to-day at school. How do you assess self-esteem? What questions are you asking the child when you

00:14:39.500 actually get to sit down with the child to determine that? And is there anything you can glean on that

00:14:45.340 dimension from speaking with anybody other than the child?

00:14:48.460 Yeah, you speak to the child and you do talk to others, both of those things. When you talk to the

00:14:53.100 child, there's multiple different ways of doing it. Not always easy to get the answer. With younger

00:14:59.500 children, we sometimes use approaches where we actually are talking about a third person. So there's a

00:15:05.460 number of different techniques where you are working with a child. Of course, you're building relationship

00:15:10.860 rapport with a child. There needs to be trust. But there's a number of ways that we assess it where

00:15:16.800 we actually may talk to them about another child so that you have another third person. Because it's

00:15:22.360 sometimes easier to talk about a third person than yourself. So talking about situations, about how

00:15:28.860 another child would feel at school. Or why does another child feel uncomfortable at school? Or why does a

00:15:35.540 child come home crying some days? And then you hear their stories. So when the children talk about that, they

00:15:41.840 actually relate to their own situations. And they start to say like, well, Johnny came home from school

00:15:47.500 crying because nobody wants to play with him. Because he always messes up rules to the game.

00:15:53.900 What is the age window in which you can utilize that technique?

00:15:57.340 It's mostly primary elementary school age. So I feel like by the time I get to a second grader,

00:16:05.040 they are second, third, fourth, fifth, they're able to share these stories.

00:16:10.720 About other people, you mean?

00:16:12.300 Yeah.

00:16:12.500 Yeah. Interesting.

00:16:13.440 Yeah. When they're older, they'll talk about themselves. It's hard to reflect on your own

00:16:17.960 feelings and thoughts. For a child to identify their own emotions and the why behind their emotions

00:16:23.680 it's challenging. So you've, in that description, actually made a pretty clear, I think, case for

00:16:30.520 some of the traits that are showing up in ADHD and in anxiety, all the different variants of it.

00:16:37.280 Let's talk a little bit more about autism. Now, of course, it was referred to as ASD, right?

00:16:42.280 Correct. Autism spectrum.

00:16:43.680 Autism spectrum disorder.

00:16:45.060 We'll park for a moment the use of the word disorder and maybe come back to that a little

00:16:49.860 bit. But tell me today, how is the diagnosis of autism made? Because I think when many people

00:16:56.760 think of autism, if they're old enough, they might think a rain man. You're going to think of somebody

00:17:02.080 who in a very short interaction, a non-clinician would go, oh, that person is not neurotypical.

00:17:09.920 That person clearly has something about them that's quirky and very different. And you might

00:17:15.480 think of even more extreme examples of children that are nonverbal and things of that nature. But

00:17:20.500 again, given the nature of this and the fact that it's a spectrum, that must make it even more

00:17:25.240 challenging to find the diagnosis, correct?

00:17:27.980 Very, very. I have so much to say about autism, the diagnosis and how we make it and how it's changed

00:17:33.700 so much over the years. So autism spectrum. So first, it's a spectrum, huge spectrum of what

00:17:40.220 this means when we talk about autism spectrum. It goes from what people remember it from decades ago

00:17:46.100 as from nonverbal, very little communication skills, being somewhat isolated, not interacting

00:17:53.520 with other people, mannerisms such as flapping your hands. That's sort of a classic description that

00:17:59.600 we do remember from over the last couple of decades. Nowadays, many children who have a lot of speech

00:18:07.640 and language skills, who do communicate a lot, but struggle with the social communication that we have

00:18:13.520 with each other, who have many, many strengths, but do struggle with social skills and do have some

00:18:20.500 restricted interests and repetitive behaviors. They also qualify under this umbrella term called autism

00:18:26.740 spectrum disorder. And this term, autism spectrum disorder, that term came out in 2013 with the

00:18:33.200 DSM-5. So how we diagnose it is based on, again, clinical traits, but the definition and the checklist

00:18:41.040 of those traits have actually changed many times over the last few decades. So currently, it is, you work

00:18:49.720 with an expert who has a lot of experience with autism, and they do an analysis of someone's behavior.

00:18:55.940 And the two areas that we look at, social communication skills, and the other is the repetitive behaviors

00:19:02.680 restricted interests. So for social communication skills, our current diagnostic criteria requires that a

00:19:10.960 patient has differences in three specific areas. One is their social reciprocity. So this is the back and forth

00:19:22.520 of social interactions. It's how do you initiate socially, how do you respond socially. The second area is related to

00:19:31.380 nonverbal communication skills. So it's how someone uses their nonverbal communication, eye contact gestures, as well as how

00:19:41.340 they understand and interpret somebody else's nonverbal communication. And then the third area is related to how they

00:19:50.920 understand relationships. So it's about building friendships, playing with peers, how they understand

00:19:59.540 the social contacts of being in a group. So those are the three key areas when it comes to the social

00:20:06.660 communication piece. And in order to get the diagnosis, you do have to have differences in all those three

00:20:12.320 areas.

00:20:12.720 Is this something that is done during one assessment or is this something that's done over repeated

00:20:17.680 assessments?

00:20:18.900 Depends on the level of severity in the child. So first of all, it's important that whoever's doing

00:20:25.080 the assessment really understands that child.

00:20:27.260 Who in your clinical team does this? What type of training does this person have? Is it a physician?

00:20:32.920 It can be a physician or it can be a psychologist. That's generally who does it. So physician would either be a

00:20:38.940 developmental behavioral pediatrician or a psychiatrist. That's most often, occasionally it's a pediatric

00:20:44.120 neurologist or somebody else with some sort of similar background and training, but generally

00:20:49.240 DBP or psychiatrist. And if it's not a physician, then it's a psychologist that usually does the

00:20:54.020 assessment. And so the assessment could be multiple things. There's no gold standard, like the assessment

00:21:00.500 has to include certain components. But again, like I mentioned, it's important that the clinician

00:21:05.720 get to know the child, I think it's important to understand the child's profile. The label is only

00:21:10.680 one piece of it. If someone tells me their child has autism, I actually really don't know much about

00:21:15.420 their child.

00:21:16.420 Say more.

00:21:17.060 Because you tell me your child has autism, I really don't know what your child is like if someone tells

00:21:21.140 me that on the street. Then we come up with treatment plans for like a child with autism. It's

00:21:24.860 like, well, there's a saying, you've met one child with autism, you've met one child with autism.

00:21:28.760 And so to really make a difference with the treatment plan, you need to understand that

00:21:35.460 profile of that child, that child's strengths and challenges. And so for me, there's multiple

00:21:41.440 goals with the assessment. One part of the assessment is to make a diagnosis because the

00:21:45.860 diagnosis can be a tool to help the adults around that child better understand that child.

00:21:53.000 It gives some sort of structure of like how to approach that child and leverage their strengths

00:21:59.460 and work on skill building. It can help get resources at school or through insurance.

00:22:06.120 So the diagnosis is a tool. However, to really make a difference, you want to understand

00:22:12.760 what about that child is unique and different and how do you support that child?

00:22:18.160 So you were asking, how do you do an assessment? So when it is a more significant case with significant

00:22:26.300 impairments, we frequently can make the diagnosis. I'll just be honest, you can make it pretty

00:22:31.440 quickly. You should take a good history. You should definitely meet with the child, work

00:22:36.960 with the child in the clinic. But there are many children where a trained clinician can do that

00:22:42.720 diagnosis pretty quickly in a child with very significant autism. It'd be obvious to you if

00:22:49.280 you were in a restaurant and you saw someone with autism. It's obvious to many people. But for children

00:22:53.400 who have milder symptoms, it is really important that there probably is multiple visits to see the

00:23:00.220 child on multiple days, that different types of assessments are done directly with the child in

00:23:06.760 addition to taking history with the parents. And in addition to collecting information from other

00:23:12.520 people involved in that child's life, such as teachers or therapists, it's important to get

00:23:17.540 different perspectives.

00:23:19.540 So you mentioned that the diagnosis in probably more severe cases can be made earlier and earlier

00:23:25.480 in life. Sounds like sweet spot is three to four years of age. But then you said half of the kids

00:23:30.700 are diagnosed above six. Yes. So is that something that is a relatively recent phenomenon of the past

00:23:38.160 decade since the DSM-5 broadened the inclusion criteria? Or was that even true in the 70s and 80s?

00:23:46.280 It's complicated. I'll say it has a lot to do with the new diagnostic criteria. So before 2013,

00:23:54.240 we had Asperger syndrome. We don't use that diagnostic label anymore. And we also had something called

00:24:00.700 PDD-NOS, pervasive developmental disorder, not otherwise specified, a mouthful. And PDD-NOS

00:24:07.840 was a term we used when it had similarities to autistic disorder, because all three of those

00:24:15.440 names were under the umbrella of autism. And so there were a lot of kids who received this PDD-NOS

00:24:21.540 because they were like... Something's different.

00:24:23.700 Something's different. They're sprinkled with bits of autism, but they didn't quite meet all the

00:24:28.700 criteria. When you didn't meet all the criteria, you got PDD-NOS. And then there was Asperger syndrome,

00:24:34.100 which generally described an individual who had good cognitive skills, average or high cognitive

00:24:41.360 skills, intellectual skills. They had a lot of speech and language skills. They actually have

00:24:46.080 huge vocabulary. But again, their social reciprocity, back and forth conversation,

00:24:52.500 picking up on social cues, that was atypical. And they also had a lot of restricted interests.

00:25:01.560 They would have things they were really interested in, but then they would dive deep into those

00:25:05.780 things. So in 2013 with the DSM-5, we put all of that together under autism spectrum disorder.

00:25:11.800 And so now the kids who have the more clear-cut, very traditional autistic disorder, they're picked

00:25:19.120 up at two years of age or two and a half, three years of age. And it's the kids who have the stronger

00:25:25.880 cognitive skills. They have speech and language present. They're picked up later. By the way,

00:25:31.060 nowadays with the new diagnostic criteria, language impairment may or may not be present in the

00:25:38.340 diagnosis. When you give the diagnosis of autism spectrum disorder, you also have to clarify

00:25:44.140 whether there is intellectual disability. So with or without intellectual disability. And then we say

00:25:51.220 with or without language impairment. With all of these changes, the spectrum, it's very broad.

00:25:57.280 Now, this is a question I'm sure you get asked all the time. So the CDC said in the year 2000,

00:26:01.500 one in roughly 200 kids, 150 to 200 kids had autism. Now, of course, that's pre this change of

00:26:10.180 the DSM-5. So we can only take that to mean that those were the kids in that bucket of more extreme

00:26:16.020 autism that did not include the PDD-NOS. Was that what the other one was called?

00:26:21.100 Yeah.

00:26:21.380 And Asperger's. But if you look at the data up until prior to that change, the last year prior

00:26:27.380 to that change in 2012, it was down from one in 150 to one in 69. So in other words, there was

00:26:34.940 something that was increasing the prevalence or diagnosis by about a factor of two. Then we get

00:26:42.260 the change in the DSM and today we're at one in 36. So it begs the question, what is it that is

00:26:51.600 driving the increase in the prevalence of ASD, notwithstanding that there has also been a larger

00:27:00.040 net cast around it?

00:27:02.000 I can't believe it's one in 36 because I've been doing this for 25 years. I can never keep track of

00:27:07.600 the numbers. Every time I go to an annual meeting, the number changes and it's one in 36 now that we

00:27:13.300 diagnosed.

00:27:13.440 Well, again, that's what the CDC said in 2020. So I'm going to go with whatever numbers you

00:27:17.240 take. I'll believe your numbers more than mine.

00:27:20.340 The point being that the numbers have changed drastically. And yes, people will say part of

00:27:25.880 it is because the definitions change, there's more awareness, there's more resources, there's more

00:27:31.440 clinicians making the diagnosis. But people in the field believe that those changes

00:27:37.260 don't explain the drastic changes in the numbers. And there has to be something else involved.

00:27:44.560 And there is a lot of research in this area looking at the impact of the environment

00:27:50.060 and epigenetics and what roles those two things have in increasing the rate of autism in our population.

00:28:01.540 If you're at a dinner party and you get cornered and everybody wants to talk about this,

00:28:05.200 how are you walking people through this? What are you saying? Let's put the diagnostic criteria

00:28:10.540 aside. Let's put the keys under the lamppost aside, meaning wherever there's more attention,

00:28:16.120 you're going to see more things. What are some of the environmental things that you think

00:28:20.460 could be amplifying this?

00:28:22.460 There is thoughts around pollution, maternal infection, prolonged fever during pregnancy,

00:28:33.380 the health of the placenta, stress, parental age. There is a lot of environmental factors that

00:28:41.820 have been implicated. But what I want to say is just to take a step back first, just kind of talk

00:28:47.320 about the cause of autism, the genetics and the environmental piece, just to make it really clear.

00:28:52.280 The word autism describes a constellation of symptoms. There are many, many causes for autism.

00:28:59.420 There isn't a single cause. What causes autism is very complex and we actually have more questions

00:29:05.520 than answers. It's felt though that it is like a 10 hit model, meaning we don't know that the number

00:29:12.220 is 10, but the idea that there's multiple- It's not a two hit model. There's many factors involved

00:29:16.760 and it's almost felt like it's gene, gene, gene, environment, environment, environment. And then

00:29:22.080 now it's like epigenetics, epigenetics, epigenetics. And so it's multiple hits and the order of the hits

00:29:29.460 and the timing of the hits are also felt to be very important.

00:29:33.180 Let's start with the genetic piece. We've had a number of folks on the podcast over time. So

00:29:39.160 the listeners are probably familiar with what we mean by the heritability of something,

00:29:43.620 but maybe just for folks that need to brush up on that, we would talk about the heritability of

00:29:48.580 a condition, whether it be depression, whether it be schizophrenia, whether it be bipolar disorder

00:29:53.320 is largely determined by you have identical twins separated at birth, raised in completely different

00:30:01.580 environments. What is effectively the probability that they're both going to come down with the same

00:30:06.700 psychiatric condition? And that's unfortunately, fortunately, that's the purest way we can get

00:30:12.620 at what the genetic heritability is of something when you don't know what the genes are or when there

00:30:17.960 are so many genes and it's very complicated. And my recollection is that the heritability of

00:30:24.760 autism is quite high. I don't remember the number. Can you enlighten me?

00:30:30.020 It'll be anywhere from 70% to 98%, depending again on the definitions used at the time,

00:30:36.900 but it's well over 90%. Wow. I didn't know it was that high. I thought it was in the 80s,

00:30:42.400 which is still very high. Am I also correct in my recollection that the heritability of autism

00:30:49.940 is higher than it is for any other condition in the DSM? I believe so.

00:30:55.960 Yeah. In other words, even schizophrenia, even bipolar, even depression and things that we know

00:31:00.880 have very strong genetic components. It is. None are as high as it is for autism.

00:31:06.260 Correct. There's definite genetic component to this. But may I say, so it's not one gene?

00:31:11.820 Yeah, I was just going to say. So let's make sure people understand.

00:31:14.080 It is not one gene. It is multiple genes. So anybody with autism, they have multiple genes

00:31:20.580 that have been changed. So there's multiple genetic changes in anybody with autism. And the other thing

00:31:28.380 is every person who has autism, they probably have a different group of genes that have been

00:31:34.300 changed. It's actually hundreds and some people say up to like a thousand genes have been

00:31:39.000 associated with autism. Yeah. So I think maybe a way that I would explain this, and please correct me

00:31:44.480 if you don't like this analogy, I liken it to cancer with a fundamental difference. So hear me out

00:31:49.900 for a second and feel free to shoot this down. Cancer is mostly about somatic mutations and not

00:31:55.620 germline mutations, meaning most of the time when a person gets cancer, it is not based on genes that

00:32:01.340 they were born with. It's based on genes that were at one point normal that have since acquired

00:32:06.220 mutations in their mutated state. They no longer function. Normally the person develops cancer.

00:32:11.280 So this complicates my analogy because only about 5% of cancers arrive from germline mutations,

00:32:18.300 whereas the genes that are implicated in autism are indeed germline. You're born with them.

00:32:24.280 However, the point I want to really make is comparing the somatic mutations of cancer

00:32:29.260 to the germline mutations of autism. And the point I'm trying to make is that when you've met a woman 0.97

00:32:35.400 with breast cancer, you've met a woman with breast cancer. You're not going to find too many women 0.93

00:32:41.500 that look the same with breast cancer. And that's really why gene therapy hasn't panned out for most 0.66

00:32:47.200 cancers. Because to say that a person has breast cancer tells you some stuff, you could dig a little

00:32:53.960 deeper and say, well, it's estrogen positive, it's progesterone positive, it's HER2-NU positive.

00:32:58.460 But still, why wouldn't they all respond the same? Well, it's because they have many different

00:33:02.460 underlying genetic changes. Furthermore, they have completely different immune responses

00:33:07.260 in terms of what their tumor looks like. And so the way I try to think about it myself is

00:33:13.740 if you see 100 kids with autism, and let's just pick a number that's somewhat conservative,

00:33:19.980 we would say that that's 85% to 90% heritable. It simply means that the underlying genes for each of

00:33:28.420 them were inherited, but they might have nothing to do with each other across all of those children.

00:33:34.020 Just as we would say, all of the women who have breast cancer have acquired mutations that gave

00:33:39.900 them breast cancer, but they could all be very different. I agree.

00:33:43.820 Again, I could poke holes in that analogy, but I think that's maybe an easier way to think about it

00:33:48.200 because polygenic things are harder to wrap our heads around, especially when we don't know what

00:33:53.400 all the genes are. Yeah. So we don't know all the genes. We know that there is this genetic component.

00:33:59.500 It's like each child with autism has a different fingerprint with their genetic makeup.

00:34:04.020 And so there's these genetic changes, but some of the hits I mentioned are environmental. So

00:34:09.660 there is research to show maternal stress, pollution, maternal diet, parental age. These

00:34:16.240 things also are associated with autism. And again, there's a long list. So there's a long list of

00:34:21.720 things that are associated, but none of them alone, each one alone is not the key to autism. It's the

00:34:28.900 combination. The thing I'm still struggling with is, let's take another example that I think we can

00:34:34.800 all point reasonably at. 50 years ago, the incidence of type 2 diabetes was in the ballpark of

00:34:41.640 1.5 to 2%. One and a half to 2% of people in the United States had type 2 diabetes. Today we're,

00:34:50.620 God, I haven't looked in a while, but it's over 10%. And I'm talking clear type 2 diabetes.

00:34:55.360 I'm not talking about in the gray area of pre type 2 diabetes. So let's just say we've had a five to

00:35:01.660 seven fold increase in a condition over the course of one generation. So then the question of what are

00:35:09.800 the environmental triggers? It would be very difficult to explain that just genetically,

00:35:14.580 that there's been some genetic change. We might have genetic susceptibilities. We might have

00:35:19.220 genetic manifestations, but the thing of it, something must have changed. And I think most people

00:35:23.580 would point to our food environment as the leading thing that has driven that change because the

00:35:29.500 change in the food environment in 50 years is dramatic. So when we apply the same logic to autism,

00:35:35.040 do we see big enough changes in these environmental triggers, even just over the last 20 years or 25

00:35:42.520 years to say, okay, 25 years ago, kids were born with the same genetic predisposition. There can't be

00:35:50.440 that much genetic drift unless we believe we are seeing more people pair together to combine four

00:35:58.300 genes or genetic combinations that are producing this phenotype more than we saw before. We can come

00:36:04.260 back to that. I'd love to hear your thoughts on that, but let's put that aside for a moment.

00:36:07.900 If we're saying that whatever epigenetic change is happening is triggered by something in the environment,

00:36:13.940 and we're talking about if paternal age is going up, if maternal stress is going up,

00:36:19.180 if maternal nutrition is getting worse, if environmental toxins, microplastics are all

00:36:25.340 over. Everybody's talking about those things, heavy metals, whatever it is. I would love to go into a

00:36:30.300 little bit more detail and get your thoughts on how those things are changing it. And we have to talk

00:36:35.060 about vaccines, of course. There's going to be a subset of people here, I think, who understandably would

00:36:39.800 think, hey, what about vaccines? Haven't we changed the way we vaccinate kids? Is that participating in

00:36:46.500 it? Now, you mentioned that this is an in utero genetic condition. If that's the case, then childhood

00:36:52.380 vaccines might be less responsible than some might think. But I'd just like to hear you riff on all of

00:36:57.340 this stuff. Because before we get into the what to do, I still think there's a lot of people asking,

00:37:02.640 how did we get here?

00:37:04.160 I wish I had all the answers. I don't. I think it's complex.

00:37:07.380 There have been changes in, you talk about diet, pollution, toxin exposure. I think that's one piece

00:37:15.040 of it. It is one piece. With epigenetics, as you know, it can be epigenetic changes, which, just to

00:37:22.220 clarify for everybody, the DNA sequence is not changed. It's about tags on the DNA that can change the

00:37:29.620 expression of genes or proteins called histones that are changed, that end up resulting in changed gene

00:37:36.220 expression. But the changed gene expression can actually be inherited or passed through generations

00:37:41.820 as well.

00:37:42.400 Yeah, I was going to ask you about that. Do we know that to be a fact that the epigenome is being

00:37:46.740 transmitted?

00:37:47.920 I think it's controversial. I think it's controversial, but there is some thought about that,

00:37:52.480 about the idea of the germ cells in a fetus, in a grandparent, being exposed to smoking,

00:38:00.820 toxins, changes in food, how that grandparent exposure can actually change methylation in the

00:38:09.140 germ cells of a parent who's a fetus, who then that germ cell goes on to be a child with autism. I

00:38:15.660 don't know if that made sense. It was sort of confusing.

00:38:16.860 It makes a ton of sense to me because I think about this problem night and day. I do want to

00:38:20.840 make sure the listeners understand that, first of all, this is not established.

00:38:24.680 Not at all.

00:38:25.460 And I want to make sure they understand what we're saying. So let's explain it one more time.

00:38:28.080 We have these four things that make up DNA, your C, G, A, and T, and that is the code. That is the

00:38:34.580 code of life. But on the backbone of those things, you can put little methyl groups, which is just a

00:38:40.700 little carbon with three hydrogens. And that's called epigenetics. And by the way, we're all born

00:38:45.120 with methylated groups all over our epigenome, back of the genome. Over life, we know that changes.

00:38:51.820 So we know that simply aging changes methylation, but we believe that there is

00:38:57.840 differential methylation in individuals in response to all the things that you've talked

00:39:01.960 about. And we know that methylation controls gene expression. In fact, methylation is probably the

00:39:07.880 single most important thing that controls differential gene expression in different

00:39:10.780 tissues. So the question, the jugular question is, if you have a methylation pattern, can you pass

00:39:17.980 that on to your fetus? And what you said a minute ago is even more remarkable, which is would

00:39:24.440 that child, when they develop, pass that methylation pattern on to their fetus. At that point,

00:39:30.500 methylation epigenetics would start to become genetic, right? It starts to become a part of

00:39:34.720 the germline. So, I mean, this is an answerable question, by the way, in my book. When I think

00:39:39.640 of things that we should know the answer to in a decade, I'm going to put this in the list

00:39:42.700 of things that we should know the answer to, just based on the fact that we will have enough

00:39:46.740 longitudinal data, I think, to be able to get at this. I don't know if you're as optimistic

00:39:50.660 as me. I am. The key thing is that we do know the environment impacts the methylation and

00:39:56.740 the epigenetics. So it's the idea of it crossing generations. It's the idea of the methylation

00:40:03.380 in a germ cell is altered or changed because of some sort of environmental exposure in, again,

00:40:10.320 that parent or grandparent. And so in that sense, the child is now susceptible to two things. The

00:40:18.080 germline that they inherit from both parents and, as a fetus, the methylation impact that occurs

00:40:27.020 as a result of any of these other factors you've discussed.

00:40:30.860 Yes. Yeah.

00:40:31.120 Who are the people that are studying this most closely? Is this in the purview of the geneticists?

00:40:36.700 Is this in the purview of the epidemiologists? Who are the people that are most working at this?

00:40:40.560 Because, again, as a general rule, I always think that it's very foolhardy to work on a problem

00:40:48.040 an epidemic without understanding the causal nature of the epidemic. I use the example of heart

00:40:54.260 therapy. Changed the face of HIV forever. One of the greatest success stories of infectious disease,

00:41:01.020 medicine. But it was all predicated on understanding what the cause was. You didn't understand that HIV

00:41:07.380 was destroying CD4 cells. You didn't have a prayer of developing that therapy.

00:41:12.500 And do you ever worry that, what's to say this isn't going to get to be one in three kids in 30

00:41:20.780 years? And are there enough people like you that are going to be able to help parents and help

00:41:26.660 families and help children with that? I don't want to sound alarmist, but I worry when we have an

00:41:31.360 epidemic, potentially, and we don't have a great sense of causality.

00:41:36.280 That's profound. And I'm thinking about a number of different things. One, I'm thinking about,

00:41:41.020 because you're talking about this one in three.

00:41:42.920 And I'm just throwing that out as, hey, what if this trend continues, right?

00:41:45.880 Yeah. And so one of the issues, though, is how we define the condition. That's the thing. So there

00:41:51.580 is still that, although I believe that there is this piece with genetics and the environment and

00:41:56.980 how we are evolving. And there's this phenotype, this phenotype where there is differences in social

00:42:04.500 communication skills and repetitive behaviors of restricted interests. This phenotype, which is on

00:42:11.520 a huge spectrum as well. I shall make sure this is the thing. When we're talking about these numbers,

00:42:16.220 like one in 36, and this number continues to increase, it's not just the kids who are like

00:42:21.280 nonverbal autism. It's this really wide phenotype is increasing. And so it is important we understand

00:42:30.680 the cause of why this phenotype is increasing. And then what should we or should not be doing about

00:42:37.840 that? What do you know about the change in the frequency or the prevalence of, let's pick one subset

00:42:46.400 of that, which is the nonverbal or child that is so impaired that I could diagnose them or a parent

00:42:54.040 could diagnose them? Do we know if that has remained relatively constant over the last 25 years,

00:43:00.200 despite the change in diagnostic criteria? I believe there's an increase in that number as well.

00:43:06.460 But the numbers that are put out there, the really profound numbers actually describe the entire

00:43:11.160 spectrum. And they don't actually subdivide into the different parts of the spectrum.

00:43:18.660 Do you have a ballpark idea? So if the overall diagnosis of autism is increased five-fold in the

00:43:25.820 last 20 years, has that more severe part gone up by 50%, by 100%? I mean, what do you think it is?

00:43:32.020 Or what do you know it is?

00:43:33.360 So we subdivide autism spectrum into three buckets, level one, level two, level three.

00:43:38.620 So the more significantly impaired children would fall into level three, where they require very 1.00

00:43:46.160 substantial support. There are very few research studies that actually look into these sub-buckets.

00:43:53.840 And I have to be honest, I'm not sure clinicians are always great at identifying kids in the sub-buckets

00:44:00.180 either. Like you and I are talking about a very specific profile that should be very obvious to

00:44:06.640 identify. But there's other kids in sub-bucket three that are sometimes put in sub-bucket two,

00:44:12.840 depending on what clinician they see.

00:44:14.800 And I'm going to guess that sub-bucket three is not the totality of the children that were called

00:44:21.400 autistic prior to 2013. Is that a safe assumption?

00:44:24.500 Yes.

00:44:25.140 So you can't even say, assuming the data existed, and it sounds like they don't,

00:44:29.900 we can't just say, what was the prevalence of autism in the DSM-4, and how does it compare to

00:44:36.740 ASD sub-3 today? That wouldn't even be a meaningful comparison.

00:44:41.300 I'm not sure if anyone's looked into it, but yeah, I don't know.

00:44:44.540 But even if they did, it wouldn't be apples to apples.

00:44:47.260 No, it's not.

00:44:48.140 Okay.

00:44:48.360 By the way, one of the reasons they actually went from the Asperger syndrome, PDD-NOS,

00:44:54.640 autistic disorder, because that was actually quite controversial when they actually decided to

00:44:58.540 put all three of those things under one umbrella called autism spectrum, was because clinicians

00:45:04.040 did a really poor job of deciding-

00:45:07.900 Which bucket you were in.

00:45:08.720 Which bucket you were in. So you would have a child, and one clinician would call it Asperger

00:45:13.420 syndrome, another person would call it autistic disorder, another person would call it PDD-NOS.

00:45:17.000 So they decided, okay, rather than having these three names, let's put it all under autism

00:45:21.520 spectrum. So then they put it under autism spectrum, but then they have level one, level

00:45:25.080 two, level three. But I would still say that clinicians still struggle sometimes where there

00:45:29.320 is a little bit of overlap. It's not always clear.

00:45:32.040 Now, if you go back to DSM-4, when, as you mentioned, physicians are struggling to know which

00:45:37.200 of these buckets to put them into, as an outsider looking in, my first question is, does it matter

00:45:43.780 in terms of treatment and resources? Does it matter more in terms of outcomes and support?

00:45:50.920 There must be a reason why people cared about that. In other words, if you had a child in

00:45:56.200 the year 2000, who one clinician said, this kid has Asperger syndrome, and another person

00:46:01.340 said, no, they're autistic. Was that going to make a material difference in the type of support

00:46:07.420 that they got? And most importantly, the type of person they were going to turn into, like,

00:46:12.600 were they going to reach their full potential in their differential capacity?

00:46:16.500 So it did make a difference with respect to resources. Children with Asperger syndrome

00:46:21.060 frequently did not get support or support covered.

00:46:24.980 You needed autistic disorder to get support. 0.81

00:46:29.020 And what about PDD, NOS? Waste bucket?

00:46:31.640 Yeah, people didn't know what to do with that. So if by putting everything under autism, then it's

00:46:36.980 like, okay, if you have autism, you should receive services. It was a tool. The label's a tool to

00:46:43.320 understand and get resources. Now, we have level one, level two, level three now. Level one is,

00:46:49.980 it says, requires support. Level two is require substantial support. Level three is require very

00:46:57.160 substantial support. My concern is that, again, when a child is level one, they don't always get

00:47:04.200 the support they need because they have so many strengths. So kids in level one, frequently they

00:47:10.320 have good cognitive skills. They have a lot of language skills. They struggle with some social

00:47:16.140 skills. And they may have some difficulties with executive functioning and coping skills at times.

00:47:22.640 But again, it's considered mild and a lot of those kids don't get support. And I think that's

00:47:28.360 unfortunate because they also are the kids that respond to intervention so well if they get a little

00:47:35.300 coaching on how do you cope with distress? How do you cope with change? How do you practice some

00:47:42.160 social skills? Not that they have to change. We don't need to change everything about them,

00:47:46.780 but giving them a little bit of support about how to, again, be adaptive in a community.

00:47:53.740 Giving that support goes a long way with that group, but frequently they don't get the support

00:47:59.220 because they're called level one. Help me understand the natural history of those kids back in the

00:48:04.120 seventies and eighties. Back in the seventies and eighties, when you and I were kids, nobody thought

00:48:08.780 anything of those kids, right? Certainly weren't going to get labeled with autism. They certainly

00:48:12.140 weren't going to show up with in-school programs to help them with their social skills and with

00:48:17.580 their communication skills. As you pointed out, they're intellectually not impaired. So it's not

00:48:22.820 like they're going to struggle in school, but there's clearly something that they're struggling with.

00:48:27.080 Obviously this hasn't been studied, but I'm very curious based on your experience and your judgment,

00:48:32.100 are those people that just went on to pick careers where they didn't have to interact with people,

00:48:36.480 but they could still do challenging cognitive work. What was the natural history of them?

00:48:39.840 There are clearly a lot of them. There are, there are a lot of them. And I think they found a path

00:48:44.700 that made sense to them. They obviously learned what their strengths were and their strengths may

00:48:49.420 have been around memory, detail oriented, following rules that are black and white. They may have had

00:48:57.120 really wonderful cognitive skills in certain areas that were less around inferring and social skills

00:49:06.180 and more concrete. And yeah, we don't have studies to say this for sure, but my guess is they

00:49:11.440 have lived happy, successful lives. A lot of them, some of them doing things that they enjoy doing

00:49:17.720 are passionate about. They probably have found ways to not engage in large social settings,

00:49:23.820 but there's a lot of careers out there that are a good match. And they also have relationships

00:49:29.080 and marriages. I just want to emphasize that people with autism get married.

00:49:32.300 I just think there's zero chance that there aren't thousands, if not tens of thousands of

00:49:37.340 these people listening to us right now, because they're adults today. And I wonder if they're

00:49:42.180 listening to some of this and they're saying this resonates. I get that. When I was a kid,

00:49:46.020 I was hyper-focused on this stuff. I wasn't interested in a whole bunch of stuff. It was a little harder

00:49:50.940 for me to interact with other kids and things like that. And yet I found my path and here I am today.

00:49:55.740 So I talk to parents all the time about this because I evaluate children. I evaluate children

00:50:02.700 for autism or ADHD. And very often when I'm evaluating the child, at some point while I

00:50:08.880 develop this relationship with the family, the parents say, gosh, so much of my child is in me.

00:50:16.120 As you are describing my child and my child's strengths and challenges, and I see me, and this

00:50:21.500 is exactly what I went through when I was young. And then they share how hard it was. And they say,

00:50:27.420 gosh, no one understood me, or I felt bad because I was misunderstood, or I thought it was my fault.

00:50:34.020 I didn't try hard enough. So I have to say it can be validating for an adult to learn that it wasn't

00:50:41.020 their fault. And this is part of their wiring. I have many, many parents who ask me, should I go get

00:50:47.500 assessed now? What do you say? I ask questions. I think information is power. I think it's good

00:50:55.800 for them to be thinking about it, whether or not they go on to actually get assessed. With the autism

00:51:00.120 piece, often they don't. With the ADHD piece, they often do because they realize actually their ADHD

00:51:05.700 traits are impacting their function and success at their job. So sometimes they will actually go to

00:51:10.820 a psychiatrist to get an assessment. But I do share with them the genetics and the family history.

00:51:15.240 So what do I say? I validate. I say, yes, you're telling me that growing up, you had many traits

00:51:22.020 that today we would classify under one of these diagnoses. You're right. It is possible because

00:51:29.600 these things do run in families and there is a highly genetic component. And I think sometimes just

00:51:35.920 that conversation can be therapeutic itself in that someone feeling validated and they have that

00:51:43.220 aha moment. Like, okay, this explains a lot. And then they can feel good as well because they're

00:51:48.240 like, okay, this explains a lot. And I've gone on and I currently have my family and I'm doing well in

00:51:55.780 many parts of my life, but it helps them also understand like, ah, but now I understand why

00:52:00.000 sometimes I do have these challenges at work or with my spouse.

00:52:04.000 It's interesting just sometimes having a perspective where now you can see your challenges

00:52:09.280 through a different lens sometimes helps a person just actually now think about, okay, now I can

00:52:15.440 adjust or understand the triggers or can reflect to think about how do I want to respond the next

00:52:21.500 time. So I think again, that information's empowering, even if they don't ever go to therapy

00:52:27.240 or do anything else, just actually starting to become informed about it can help.

00:52:31.940 Yeah. And I would imagine it helps them a lot with their child because they're seeing both,

00:52:37.320 Hey, my child has this diagnosis that now partially explains, you know, the challenges we might be

00:52:43.200 having, et cetera. But at the same time, because I can empathize with that child, if I've experienced

00:52:48.980 it, it makes you a better parent. So everything you said makes a great case for widening the diagnostic

00:52:55.800 envelope. Because if we go back 40 years, we had this narrow, narrow envelope. In other words,

00:53:04.060 we had a test that had very, very high specificity, but very low sensitivity. You were missing a lot of

00:53:10.980 people, but you didn't get any false positives. That's for sure. You didn't over pathologize when

00:53:17.340 someone was autistic. They were really autistic. Today we have the opposite problem. We have a high 0.59

00:53:23.000 sensitivity, low specificity test, sort of. I'm making that up, but you know, just to bring it

00:53:27.500 to cancer diagnostics for people. So now anybody who's autistic should get diagnosed, but then we're 0.96

00:53:33.620 stretching what that means. And a lot of the people getting diagnosed today, frankly, maybe without any

00:53:39.460 support would go on to do just fine. Do you worry that when the DSM-6 comes out, it could have a wider

00:53:46.320 envelope and we could start to get to a point where someone might say, Hey, are we over pathologizing this?

00:53:52.340 And are we getting to a point where, well, what does normal even mean anymore?

00:53:57.100 I agree with that so much. So I actually ask that question all the time. I do wonder every time a

00:54:02.880 child has a few of these traits, whether or not we're coming up with the diagnosis every time someone

00:54:10.960 is just a little bit different. And rather than realizing there is neurodiversity, we're all different.

00:54:17.920 We have to give a name to it all the time. It's an interesting debate and you will have your

00:54:22.260 different perspectives. I mean, the name gives us a way to get resources and help people. But I also

00:54:28.640 concern that we have to give everything a name. I actually wonder in the next DSM, whether we'll

00:54:34.720 tend to take it a step back, whether the pendulum will swing a little bit.

00:54:38.120 And when does that do?

00:54:40.020 I don't know.

00:54:41.480 What was the gap between three and four and four and five? 15 years?

00:54:45.700 I would say a couple of decades.

00:54:46.880 It could literally be another decade.

00:54:48.320 It can be. But level one, we were talking about level one autism. So I'm concerned that

00:54:54.220 the kids in level one autism might actually be part of several different diagnostic buckets.

00:55:02.140 Children who are identified with level one autism, they see one clinician, that person may

00:55:06.900 diagnose ADHD plus anxiety. They don't even call it autism. I see this all the time in my clinic.

00:55:16.400 I have kids who come to clinic and they may see three other clinicians before they saw me.

00:55:21.180 Really great clinicians, high standards, experts, but there's a lot of blurry lines with the level

00:55:28.600 one autism and you will hear different diagnoses. So back to your thoughts around future DSMs,

00:55:35.480 I wonder how we're going to address level one autism. And is it the same condition? How many

00:55:41.420 different conditions are in that bucket?

00:55:43.980 See, to me, the way I would think about that is I would hope that by the time we have to make that

00:55:47.800 decision, we would have enough data. And the data would ask the most important question, which is

00:55:52.460 how are we impacting outcomes? In other words, when we widened the diagnostic envelope and said that

00:55:58.200 we're going to now have this ASD class one in here, that opened the door for more resources.

00:56:02.880 That meant more kids had programs at school. What's a IEP?

00:56:07.300 IEP.

00:56:07.820 IEP. More kids have IEPs at school. What does that stand for? Individual?

00:56:11.600 Education plan.

00:56:12.840 Education plan. And at the end of the day, what we want to know is, are those kids doing better?

00:56:17.780 And if the answer is yes, then it's probably worth keeping. If the answer is that didn't make a darn

00:56:23.100 bit of difference, all we did was create a bunch of anxiety for the parents and maybe it didn't.

00:56:28.180 Now, again, I don't know how one goes about answering that, but I would hope that somebody

00:56:32.440 a lot smarter than me is thinking about it through that lens because we can't lose sight of the whole

00:56:36.920 purpose of this. Like the purpose of a diagnosis anywhere in medicine should be to impact an

00:56:42.480 outcome. A diagnosis for the sake of a diagnosis is not a particularly valuable tool unless you're

00:56:48.760 an epidemiologist. But even there, it should be all in the spirit of how are we making people

00:56:54.000 better?

00:56:54.840 I agree. And that's why, again, I agree that the kids in level one should be receiving services.

00:57:00.780 Otherwise, what's the point of giving the diagnosis?

00:57:02.900 Yeah.

00:57:03.220 So they should be receiving services.

00:57:05.260 And if we need to call it something by a different name, who cares? As long as it gets

00:57:09.980 the service that makes them better off than they would have been had they received no service.

00:57:14.940 Before we get into more of the details about what you do specifically treatment-wise, I want to finish

00:57:21.520 one other bit of the diagnosis piece, which is can you talk a little bit about the overlap? You just

00:57:27.940 did it sort of a second ago about ASD, ADHD, and anxiety. How often do they overlap? What do those

00:57:35.760 Venn diagrams look like?

00:57:37.440 I'm going to start off by saying we diagnose anxiety in kids and there's that bucket. And there's many kids

00:57:42.480 who just clearly fall in the anxiety bucket and meet criteria. And it's really clear to see that.

00:57:48.940 There are kids who have ADHD and clearly meet diagnostic criteria for ADHD and fall in that

00:57:56.460 bucket. And then there are kids who clearly fall into the autism bucket. I'm going to focus on the

00:58:01.700 autism bucket first. So we say that about half of kids with autism also have a diagnosis of ADHD.

00:58:11.260 If you look at the numbers, you can find reports for anywhere from 40% to 70% of kids, but we say

00:58:19.540 about half of kids with autism actually do have a diagnosis of autism. Interestingly, before the DSM-5,

00:58:25.220 before 2013, we were not allowed to give both those diagnoses together. So they were mutually

00:58:30.480 exclusive. If a child had autism, we did not give a diagnosis of ADHD. So starting in 2013, we did,

00:58:37.280 and we give it a lot. So a lot of children with autism have ADHD symptoms as well. And we give that

00:58:44.380 diagnosis. And about 40% of kids with autism also have anxiety. This makes sense when you think about

00:58:54.140 the parts of the brain involved. When you think about ADHD, we're thinking about executive functioning

00:58:58.600 skills. We're thinking about prefrontal lobes. When you're thinking about anxiety, you're thinking

00:59:04.440 about the amygdala. And then when people have done neuroimaging studies in kids with autism,

00:59:10.580 we find there's many areas of the brain involved. But in particular, frontal lobes, the amygdala,

00:59:16.940 as well as the cerebellum, temporal lobes, there's many, many areas of the brain involved. But kids with

00:59:23.160 autism do have challenges with executive functioning and anxiety, although those are not part of the

00:59:28.320 diagnostic criteria. So those are associated symptoms, associated traits, associated diagnoses.

00:59:35.440 So they're comorbidities, not part of the core diagnostic criteria. But there's a lot of overlap.

00:59:41.240 If 50% of them have ADHD and 40% of them also carry a diagnosis of anxiety, is there a percent of those

00:59:48.980 that are overlapped and have all three?

00:59:50.380 Yeah. A lot of them have all three. I don't know the exact number for that one.

00:59:53.600 Okay. This is the thing. These kids, they present with the core features of autism along with the

01:00:00.120 executive functioning challenges and are anxious. Okay. So now what can we say about kids with ADHD

01:00:07.940 and anxiety? What's that overlap? Kids who have ADHD and anxiety, their numbers towards autism are not

01:00:14.900 as high. So there are a lot more kids with ADHD who are not diagnosed with autism. But there's a lot

01:00:20.980 of overlap between ADHD and anxiety. So ADHD frequently has a partner, is what I tell families.

01:00:26.940 If you have ADHD, you often have either anxiety or some other mood challenges, or you have learning

01:00:36.040 differences. So learning disabilities are frequently present to kids with ADHD, or you have oppositional

01:00:41.960 behaviors. So there's often a second condition present in kids with ADHD.

01:00:48.260 Say more about oppositional behavioral tendencies.

01:00:52.000 So there is a diagnosis out there called oppositional defiant disorder. That is a diagnosis

01:00:58.800 that I don't use quickly or often in young kids when I see oppositional behaviors. This is my personal

01:01:08.140 approach, is that I will say I see a child with oppositional behaviors. What does that mean?

01:01:14.000 It means someone who argues, doesn't follow rules, disobeys, lies. So kids with these types of

01:01:21.640 behaviors, I want to understand the why's before I jump into saying that they have oppositional defiant

01:01:27.580 disorder. Technically, maybe they meet the criteria. Again, it's a checklist criteria for that name.

01:01:33.420 But to me, that name doesn't help me. It's just a name. It's like, okay, I have a kid with ODD,

01:01:38.540 we call it. It's like, how does that help me? What do I do with that? So if I see a child with

01:01:43.420 oppositional behaviors, I'm like, okay, what's the function behind that behavior? And so I can come

01:01:48.500 up with reasons for why a child is oppositional. So we all have seen kids who have meltdowns,

01:01:54.420 who fight, who yell, who argue. It's like, what's the function behind that? And so it may be that child

01:02:00.220 is actually anxious. I'll tell you a lot of oppositional behavior in kids is driven by feelings

01:02:05.260 of anxiety and embarrassment. It may be the child is impulsive. That child lies and argues and yells

01:02:12.860 no quickly because they're impulsive and they have untreated ADHD. It could be that child struggles with

01:02:19.120 understanding social contexts and social skills. They actually have trouble with their social

01:02:23.920 reciprocity, but they're presenting with what looks like oppositional behavior. That child may be

01:02:30.500 sensory overloaded and have challenges processing sensory information and therefore becomes overwhelmed

01:02:38.040 and dysregulated and oppositional. The list goes on. The point is, is like when I see a child with

01:02:43.820 oppositional behavior and a family says, oh, well, someone told us it was ODD. I'm like, now what?

01:02:51.120 I want to come actually right back to that. I don't know what fraction of kids are getting that type of

01:02:56.000 insight and attention, but my concern would be not enough. My concern would be that we're just in a

01:03:01.440 world of ever expanding labels and codes and the so what is missing when of course there isn't really

01:03:11.000 a field of medicine in which the so what matters more. If you think about this person has hypertension,

01:03:16.780 hyperlipidemia, insulin resistance, it's important to understand why. But at a minimum, we have great

01:03:22.920 treatments if we don't know the why. If at the end of the day, it's just deemed essential hypertension,

01:03:28.000 we have no clue why. Worst case scenario, we can put you on medication. If weight loss isn't enough

01:03:33.020 to reduce your blood pressure and fix your insulin resistance, at least we've got medications that

01:03:37.120 work really well. But a lot of people would be hesitant to give their kids medication here. I want

01:03:43.240 to talk, of course, about this in length, which is all the more reason why, boy, if you don't

01:03:49.200 understand why this kid has oppositional defiant disorder. If it's because if it's like sensory

01:03:54.540 overload, it's a totally different treatment path than if it's anxiety. I agree. And so this is one

01:04:02.080 of the challenging things about my field. And again, I'm going to come back to my boxes. I see a family

01:04:06.960 and I'm actually pretty transparent with the families I work with regarding that we don't know

01:04:11.660 everything. I am really honest with them and transparent because they're like, doctor, what is the

01:04:16.660 diagnosis? And the thing is, is families, they want to find a diagnosis because it helps. It's scary when

01:04:22.140 you don't know what's happening. But I really walk them through that there are these labels and

01:04:27.320 diagnoses, but the risk is that they can see someone in my field and they do testing and you give a

01:04:34.300 diagnosis. Like I have kids, they come with a report, this child has ODD. And I'm like, okay, well,

01:04:39.280 what does that mean? What are we going to do about it? And so the why is so, so very important

01:04:44.340 with, again, comes back to how do we create treatment plans? And it comes back to, again,

01:04:49.260 like I said, you've met one child with ODD, you've met one child with ODD. And ODD to me means

01:04:53.640 actually, I don't even know what to do with that. There's no treatment for ODD. But however,

01:04:58.500 if I know if the child has impulsivity, I can treat that. If the child has social difficulties,

01:05:03.500 okay, I know what kind of treatment plan to create there. If the child's anxious, I know what type of

01:05:07.720 therapies to give. So it's really important to think about the why. It was actually one of the

01:05:13.320 things when I left the traditional medical model and started my clinic. One of the things that I

01:05:19.620 really noticed when I was making that transition and one of the things I wanted to remember when I

01:05:23.560 started to work with families in my clinic was that it's not just about the diagnosis,

01:05:28.640 it's the journey afterwards. And it's really about personalized care. And you can make such a big

01:05:35.440 difference in child development, human well-being by really understanding that specific child.

01:05:42.380 And unfortunately, sometimes when you're on the treadmill in a medical model,

01:05:46.980 it's really hard to have the time to really get to know a child. And I felt like I was,

01:05:53.220 you have autism, here's a list of 15 recommendations, good luck. And you have ADHD,

01:05:57.720 here's a list of 15 recommendations, good luck, without really getting to know the why behind that

01:06:02.520 child's behavior. Yeah. And I'm trying to think about how you compare this to adult psychiatry,

01:06:08.000 right? Where psychologists and psychiatrists who really help people tend to focus less on their DSM

01:06:16.360 five, in this case, diagnosis. They use that. If there's a diagnosis there, we should know what it

01:06:22.020 is. And it paints the contours of what we think about. But as my friend, Paul Conti always talks

01:06:27.280 about, he's like, if you don't know their story, you can't really help them. Now, that doesn't mean

01:06:32.460 that knowing their story precludes using pharmacologic agents when appropriate. But what

01:06:37.240 it means is you have to really understand the root. Is this a response to trauma? Is this a

01:06:42.820 response to an underlying biologic condition? And again, I feel like, based on the little bit I know

01:06:48.800 here, adults seem to have more access to that kind of mental health care than children do. Is that a

01:06:54.680 misperception on my part? No, I agree. I agree. I don't think we've done enough in pediatrics in this

01:07:00.060 area. But I agree, you have to know the story and understand the whole child. And so one thing

01:07:05.920 about developmental behavioral pediatrics, which, by the way, is a very young specialty.

01:07:10.880 You were the first person at Stanford in that group. You created the group.

01:07:15.420 Yeah. So developmental behavioral pediatrics was only recognized as a subspecialty by the American

01:07:21.280 Board of Pediatrics in 1999. So it's a very young specialty. But a key thing about this field

01:07:27.820 is it's what we call a biopsychosocial specialty. And so what that means is we think about the

01:07:34.700 biology, the genetics, the brain, the biology, the medication. We think about the biology.

01:07:40.440 The psycho part is the mental health piece. So it's the idea of to support child development

01:07:46.340 and behavior, you need to consider the physical well-being as well as the mental well-being.

01:07:51.060 And then the social piece is the fact that we don't live in isolation. We live in communities.

01:07:56.700 We live in dynamics. And in order to help kids with their development and behavior, what better way to

01:08:03.160 promote human well-being and health than to start early on and impact child development and behavior

01:08:09.460 and self-esteem and learning? The way to do it is you not only think about the biology, you think about

01:08:14.940 the mental health, and you think about the social, which is about family dynamics, parenting, school

01:08:22.820 and education. This is key. This is the bridge between education and medical health, which honestly

01:08:29.720 is hard to do in the traditional medical model, bridging to education, but it is really, really

01:08:35.300 important. That's where our kids are learning and developing and growing and exposed to experiences.

01:08:40.760 And so DBP looks at that whole picture. And I really believe that that is the way to support

01:08:47.240 child development and behavior, whether there's a diagnosis or not.

01:08:51.240 Let's talk a little bit about your journey. You got to Stanford in 04.

01:08:54.940 Yeah, my husband got there in 04. I was there in 05. So I did my DBP training at the Hospital for Sick

01:09:02.180 Children in Toronto. So I'm Canadian. Trained at SickKids, an incredible place to train with volume of

01:09:07.760 cases and complexity of cases. So it was a fantastic place.

01:09:11.900 Yeah, probably one of the three largest children's hospitals in the world, right?

01:09:14.740 Yeah, it is. It is a fantastic place to train. And so I did pediatrics, pediatric neurology and

01:09:20.360 developmental behavioral pediatrics there. My interests and passions were always genetics,

01:09:25.240 the human brain, developing human, neuroplasticity. I did a lot of research in neuroplasticity.

01:09:31.200 And then 20 years ago, moved to California in the Bay Area and took a job at Stanford.

01:09:37.540 But the field of DBP was brand new. So as I said, like it is just starting out. So they did not have

01:09:43.980 a developmental behavioral pediatrician yet at Stanford. So I was the first there. After me,

01:09:48.980 they hired an incredible developmental pediatrician by the name of Heidi Feldman, who then created the

01:09:54.640 division of DBP at Stanford. And she's still there. And they have a fantastic group there now.

01:09:59.880 But I arrived, there was nobody else. I was at Stanford for a number of years and did research,

01:10:05.960 clinical work, as well as medical education teaching. And then after that, I focused on

01:10:10.680 the clinical piece and went to a large clinical organization, did clinical work. But then 10

01:10:15.960 years ago in 2014, decided to leave the traditional model and start my own multidisciplinary clinic.

01:10:24.040 So tell me a little bit more about why. What was happening prior to 2014 that you didn't enjoy?

01:10:29.880 I felt that I could help my families and patients more and or differently. I wanted to make an

01:10:36.520 impact. That's one of my passions is always to make a difference. And I felt that I was a little

01:10:42.480 bit stuck in the model. And it's just the medical model. There's so many good things about it. But

01:10:48.200 to help the families the way I wanted to, with my values, which I can describe, I needed to leave.

01:10:53.700 And what did I value? So one, I believe in promoting health and well-being. And that's all

01:11:00.000 about DBP, development of behavior. It's about promoting health. Where medical centers have been

01:11:06.040 in the past, primarily focused on treating disease. So that was one thing. Two, I really believe in

01:11:13.420 multidisciplinary teams and really having an integrated team. In this area, as I described,

01:11:18.880 understanding the whole child requires not just a physician, requires therapists, psychologists,

01:11:24.660 teachers, different types of professionals. And I really believe that to make a difference,

01:11:29.640 those professionals have to be integrated. If you want a touchdown, all the players need to be

01:11:34.440 reading the same playbook. And so I felt like a lot of the families I was seeing, they would come see

01:11:39.360 me in the medical center, the doctor. But there was the school and there was the therapist. And we had

01:11:45.000 all these different silos. I really believed I needed to bring the silos together. Another thing

01:11:49.620 is I believe in community collaboration. So that's actually the bridge to education. And that's

01:11:55.000 actually really hard to do in a standard medical model is to really have collaboration with the

01:12:00.420 school. So now I do school observations. I go to IEP meetings. I work with teachers in classrooms

01:12:06.380 because I know that to move the needle with the patients I see, I need to do that.

01:12:11.380 You need to see what the kid's doing at school.

01:12:12.720 You need to see what they look like at school. And then I believe that the family is the patient,

01:12:17.060 not just the child. If I am going to make a difference in a child's life, I work with the

01:12:22.220 parents a lot. It's amazing how powerful parenting can be and training parents. And again, this is the

01:12:29.380 social piece, the dynamics, understanding the whole family situation is really important to make a

01:12:34.720 difference in a child. And then lastly, I believe I love learning and being innovative and thinking

01:12:40.700 outside the box. And so I decided to set something up where I can continue to ask questions and

01:12:48.700 challenge the system and try to make it better.

01:12:51.780 So tell me about your team. You said you have 25 people on the team.

01:12:54.960 So we have a few different programs. We have a behavioral team where we focus mostly on kids

01:13:01.040 with autism. However, probably about 20% of the kids who work with our behavioral team

01:13:06.100 don't have a diagnosis of autism, but do benefit from behavioral therapy, social skill groups,

01:13:12.740 parent training that focuses on behavioral models. We have a mental health therapy team

01:13:18.000 that supports kids and teenagers with anxiety, depression. So we offer different types of

01:13:23.700 therapy for that. Mood, dysregulation, ADHD. We have psychologists who do testing for diagnostic

01:13:31.000 assessment. And then we have a medical team, but it's not just giving medicines. I do prescribe

01:13:36.540 medicines. But again, it's like that is a portion of what I do. I look at the whole child and it's

01:13:42.500 really understanding the therapies, the parenting, the school piece, and medication when it's important

01:13:50.120 and can help.

01:13:51.720 So there's something called ABA. Remind me what it stands for.

01:13:54.620 Applied Behavioral Analysis.

01:13:55.740 Okay. It seems to be a somewhat polarizing topic in the field of autism therapy. Maybe describe

01:14:03.160 what ABA is and explain perhaps why it's so polarizing.

01:14:06.820 Yeah. So ABA means a million things these days, and just like autism means so much as well.

01:14:14.380 So ABA is a behavioral intervention that traditionally has been used with kids with autism. It is about

01:14:21.060 taking a skill and breaking it down into smaller sets, smaller subsets. Traditionally, it was very

01:14:28.800 direct, adult-directed, repetitive, working on a small skill. All these small skills add up to a

01:14:36.440 bigger skill.

01:14:37.320 What's an example?

01:14:38.480 So an example would be, oh, you put me on the spot and I got to think of an example now. That's

01:14:44.100 really good. Okay. Let's think of something. It might be something to do with greeting someone.

01:14:48.700 Okay. Appropriate greeting. And appropriate greeting would be integrating verbal as well as

01:14:54.900 eye contact, as well as maybe turning your body towards the person. So when you greet them, when you

01:15:01.120 meet a new person. And so for someone with significant autism, that's difficult and they need to learn

01:15:07.360 how to turn their body and make the eye contact and do the vocalization and how to integrate that.

01:15:14.820 So for that skill, you'd work on the different subsets. And so you might be first working on, if you want

01:15:22.080 to greet someone and acknowledge them, you're first going to look at them and have that joint attention.

01:15:27.300 So you're going to teach a child how to make eye contact. Initially, we did ABA with something called

01:15:34.180 discrete trial. That's why it's controversial. Discrete trial, which is still used today and still can be

01:15:39.460 very helpful when it's combined with more naturalistic forms of ABA. Discrete trial would be

01:15:45.860 about teaching a child to make eye contact and they get a reinforcer every time. So make eye contact,

01:15:51.140 get a reinforcer, positive reinforcer. So it's positive reinforcers. It is a lot of repetition,

01:15:58.400 practicing teaching a child a new skill. And then you would add the other layers to it, the eye contact,

01:16:04.040 and then the greeting and the vocalization, turn your body, you would add all that together to come

01:16:08.740 up with this larger thing of how do you approach someone. So discrete trial has been around for

01:16:13.340 decades. That's the part that's controversial because people say, oh, this is very repetitive

01:16:17.340 and it's not based on relationships. So over the years, there have been more naturalistic ABA

01:16:24.040 methods created. Naturalistic in that it occurs more in a child's natural environment.

01:16:30.340 It is not just at a structured table where you and I are practicing eye contact. Natural environment,

01:16:37.420 also trying to understand the child's natural motivators. So for example, it might happen at a

01:16:43.200 park and it might happen, we know that child loves to be on the swing. So rather than sitting at a table

01:16:49.840 and me saying like, make eye contact, here's your reinforcer, make eye contact, here's your

01:16:54.020 reinforcer. Now we're at a park. This child wants to be pushed on the swing. Well, we're going to help

01:16:59.300 this child learn that if you want me to push you on the swing, you got to look at me and somehow

01:17:06.220 acknowledge me so I go push you. Otherwise, I don't know that you want to be pushed on the swing.

01:17:11.720 And so those are more naturalistic forms. One of the most naturalistic forms is something called

01:17:16.980 pivotal response treatment, PRT, which is actually training the parents in these skills because that's

01:17:25.000 really what it's about. It's not about whether this child can make eye contact with therapist A at the

01:17:31.940 table. It's about how does this child understand how to use eye contact, when it's appropriate to use

01:17:38.980 it and the power of it in natural settings. And so when you train the parents how to do it, then they

01:17:45.640 can practice at the park, at the coffee shop, on the playground, the parents. So that is the most

01:17:52.080 naturalistic form teaching the parents. This comes back to parents, how powerful it is if you teach

01:17:56.920 parents. But parents work with the child in a natural setting with natural motivators.

01:18:02.060 Are there limitations to treatment in families with single parents?

01:18:06.440 Yes. When you said that, I'm thinking like it's just a single parent. It's time and resources and

01:18:13.180 driving to therapies. Again, it depends on how significantly impaired your child is and how many

01:18:18.880 therapies they need. Yeah. And I'm just trying to understand what the socioeconomic toll is. So I

01:18:25.420 guess think about that in multiple ways. So what is the typical cost of therapy? So how much of this

01:18:30.760 cost is covered by insurance typically? How much of this cost is embedded within the school program?

01:18:35.600 So obviously, I think an IEP is included if a kid's in public schools, correct? Yeah. If they qualify

01:18:41.540 for IEPs. Yeah. But is ABA therapy or PRT or any of these things, are they covered by insurance

01:18:48.220 companies for kids? They can be. It depends on the state. So how it's covered is different in different

01:18:55.720 states. I'm from California. So in California, ABA is covered if you have a diagnosis of autism. That's where

01:19:05.360 the diagnostic piece is important. So then it is covered. And what about the impact of other

01:19:10.760 siblings? So is there anything that you've noticed about the nuances around if a kid has an ASD

01:19:17.480 diagnosis and they have other siblings that don't have diagnoses or they do and where they are in birth

01:19:23.720 order and trying to understand the overall family environment and how it pertains to treatment?

01:19:29.780 Yeah. There's actually so many things you can say about that. So I'll first start by saying that

01:19:35.200 siblings of children with autism are themselves at risk for either autism or autism-like traits or

01:19:44.920 something called the broader autism phenotype. They may actually not have autism, but they may have a

01:19:49.540 few traits of it and or at risk for other developmental disabilities. So kids who are siblings also at risk

01:19:56.120 for language delays, anxiety. So already they have, again, that predisposition, that load to have some

01:20:04.440 developmental differences. So that's one. And how much of that is based on the fact that this is a

01:20:09.820 largely genetic condition and if they're siblings, they share genetic traits even if they don't have

01:20:14.320 all of them? And how much of that is the siblings develop those in response to anything from mimicking

01:20:21.960 the sibling with autism to responding in frustration to the behaviors of the kid with autism?

01:20:28.040 There is a big genetic piece to this. So they truly do have these conditions, language delay,

01:20:35.200 autism traits, ADHD. It's very often you see a sibling with one of those other conditions

01:20:40.360 and there's that genetic piece. But you're right, there's a behavioral component, coping component,

01:20:46.420 anxiety component that may be related to family stress, attention-seeking behavior. At the same

01:20:56.180 time, I also see the opposite. I also see many siblings who have incredible empathy for people

01:21:03.620 who are different because they have a sibling who has a developmental disability.

01:21:09.180 Okay. So going back to ABA, from hearing you right, I'm not hearing you say it's good or bad. I'm

01:21:14.460 hearing you say it's just another tool in my tool bag and it has elements of it that are valuable if

01:21:20.960 applied probably in the environment of the child. So I do recommend it. It should be a part of a

01:21:27.900 child's treatment plan. The tricky part is you want it done with people who are well-trained,

01:21:34.800 who understand autism, who understand behavioral therapy well. That's the why it's sometimes

01:21:41.620 controversial is because there is such a huge demand for therapy for kids with autism. Because

01:21:47.820 the numbers are so high, it's hard to find enough people to provide therapy. It's also, it's an

01:21:55.780 industry. And there's people who take jobs in this industry who actually are not well-trained or

01:22:02.540 well-supervised or really understand the nuances. Because if you know one child with autism, you know

01:22:09.320 one child with autism. And if you're just following a recipe, you might run into people, therapists who

01:22:15.100 are not making a huge difference and are not that helpful. But I do offer it. I do recommend it.

01:22:21.880 What is the current size of the autism treatment industry and how does it compare to what it looked

01:22:28.420 like 20 years ago? In other words, has it grown commensurate with the increase in the prevalence

01:22:33.560 or is there a greater burden on the per capita therapist today?

01:22:38.480 There's a burden. I don't know the exact numbers, but it's grown. But because it's growing,

01:22:44.040 it's scaling. And when you scale- You dilute.

01:22:47.660 Yeah. You run into issues with quality when you scale. So it's hard. But that's the thing. How do we

01:22:53.120 keep up?

01:22:53.720 So what do you say to a parent who's listening to us, who's trying to navigate this for their child

01:23:03.620 and they don't live in the Bay Area, so they don't get to come and see you. What questions are they

01:23:08.780 asking? What are they trying to do to find the best care for their kids, regardless of where they lie

01:23:16.020 on these spectrums of anxiety, ADHD, or the various levels of ASD?

01:23:22.380 So what my advice would be for them would be start with your pediatrician. You start with your

01:23:27.920 pediatrician, but you need to find, your hope is with the pediatrician that they are able to connect

01:23:33.960 you to resources and the network because you really need to find a team. It's finding a team.

01:23:41.080 How likely is that?

01:23:42.560 It's hard.

01:23:43.160 Yeah. If you don't live in Boston or San Francisco or the major cities,

01:23:49.660 I'm guessing that this multidisciplinary approach does not exist.

01:23:53.380 No, it's not easy to find.

01:23:55.620 So what are the options then? What's the next best thing?

01:23:58.700 Yeah. You try to create your team. But the thing is, I talk to families all the time. This is so

01:24:03.060 stressful for a parent who's in a situation like this because they don't know anything about this.

01:24:09.040 They could be highly educated. And then we're talking about families who actually,

01:24:12.280 if you speak a different language and don't have higher education, this is a disaster. But even 1.00

01:24:17.120 for families who are well-educated, trying to understand and quarterback this, basically you

01:24:22.220 need a quarterback to help you decide, is this ABA helpful or not? Should I be focused on speech

01:24:29.120 and language therapy or ABA therapy right now? What should I be advocating for at my IEP meetings?

01:24:35.380 You really need someone to help you with that roadmap. So we need to help families more with

01:24:42.340 that. I think of myself as a Sherpa sometimes, guiding people along this journey. And it's the

01:24:47.540 roadmap. Every year we pivot and turn, where should we spend more time? Is it in social skill groups?

01:24:53.520 Is it speech therapy? What should we be asking for? And so your question is like, yeah, this is hard

01:24:59.140 to find. And so if you can't find it, you're looking for somebody. It may not be a doctor.

01:25:05.100 It might end up being a really good ABA therapist or a psychologist in your community who can help

01:25:11.940 connect you. There are state programs. What is a parent asking when they meet a provider to figure

01:25:18.860 out, is this going to be a good fit? I mean, obviously one option is just ask nothing and wait

01:25:23.520 and see how it pans out. And in six months, ask yourself the question, hey, is my kid doing better

01:25:27.380 today than they were six months ago? But if you, as a parent had the chance to meet several providers,

01:25:32.860 so the, hey, look, I happen to be lucky. I live in a city. There's three ABA providers here. I'm

01:25:38.100 going to go and interact with each of them. What could I as a parent do to understand where should

01:25:44.640 I go first? Which of these three should I pick? What are the clues that tell me this person is going

01:25:50.540 to have a higher probability of success? So one thing is that you make sure that they

01:25:56.500 have the philosophy, one size does not fit all. So that is key, is that this person needs to

01:26:03.180 understand personalized care and that they don't just give the same treatment recommendation,

01:26:09.320 same thing to every single child. It's not black and white. So you need to make sure that that provider

01:26:15.220 is flexible in their thinking and their treatment approach so that they can provide individualized

01:26:22.000 cares. One. Two would be that they would be proactive in helping you create some sort of team. So it may

01:26:33.500 not be a team like I have under one roof, but they are open to the idea of collaboration meetings with

01:26:39.900 the child's speech therapist or teacher. So someone who is open to it, but will also be proactive in

01:26:48.540 arranging collaboration meetings, maybe once a season. Three would be, I think someone who has skills

01:26:57.640 in, I mentioned the parent training piece. I think that's a really important piece. It's not just parent

01:27:03.980 education. It actually is parent training because I've seen that really make a difference.

01:27:11.680 I think that's a great list. I'm thinking about this through the lens of how do you scale what

01:27:16.680 you're doing? And there's two ways to do it. One is you just keep replicating a model that looks just

01:27:22.740 like yours. So really big multidisciplinary model, but that can only be supported in a certain geography.

01:27:28.900 I mean, to have a team the size of yours, you're not going to be able to put that in every town.

01:27:32.640 And yet I think it seems unlikely that this is a condition that discriminates by geography.

01:27:38.040 And therefore there's got to be half the kids in this country that have any of these conditions

01:27:42.040 are going to be in areas where they're never going to have large turnkey multidisciplinary

01:27:46.860 offerings at their disposal. So their parents are going to have to do sort of the heavy lifting.

01:27:52.680 And unlike cancer, so if a child gets cancer, a parent and family can go to another city for

01:27:58.920 treatment. If you happen to live in Austin, Texas, when your kid gets a certain type of cancer,

01:28:04.240 but Boston Children's Hospital or pick your favorite city that has the greatest center for that,

01:28:09.500 it's not an unreasonable thing to potentially go there for treatment. But this is not something

01:28:14.200 you're going to go and do in another city. It has to be an integration into your life where you are.

01:28:18.560 Yeah. This is the journey. This isn't a quick thing. This is years. This is a journey. And the

01:28:25.360 whole point is to have it integrated and generalized in the child's life. We were just talking how ABA

01:28:30.860 in some structured clinic, that's not our goal. The goal is to have a child showing us these skills

01:28:37.260 in real life, in their real life, in their classroom.

01:28:39.660 So what percentage of the children that present to your clinic with a diagnosis of ADHD plus or minus

01:28:46.440 anxiety require pharmacotherapy in your clinic, in your experience?

01:28:51.760 Before I answer that, I'm just going to emphasize. So kids who come to my clinic with ADHD often come

01:28:58.020 to me, not always, but often come to me because it was a little bit more complicated than straightforward.

01:29:03.340 Right. There's a selection bias into your clinic. If this were straightforward,

01:29:06.800 they wouldn't be coming to you.

01:29:08.680 Yes. If it was straightforward, hopefully their pediatrician can manage it.

01:29:11.480 Okay. Yeah. Makes sense.

01:29:12.740 Yeah. But still, the percent of kids who are treated with medication depends on the age of the child

01:29:20.280 and the severity of the ADHD. So younger kids in my clinic, I will use behavioral interventions first.

01:29:29.840 Define young. What does that cut off for you?

01:29:31.820 So I see preschoolers who come to me because they've been asked to leave multiple preschools

01:29:38.660 because they are hyperactive. And in that preschool years, although you could technically make the

01:29:45.540 diagnosis, I share with the family that we're probably going down this path, whatever we're

01:29:49.980 going to call this in the next couple of years, let's start working towards helping your child

01:29:54.000 build skills to regulate, manage their hyperactivity, manage their impulsivity.

01:29:58.820 So we start with first-line treatment for ADHD in kids under six is behavioral parent training.

01:30:07.300 So that's first. So under six, it's behavioral parent training. We do that first and try to get

01:30:12.460 that to help. We may or may not need to add a medication. The guideline for six and older,

01:30:18.960 first-line treatment is medication plus behavioral parent training. And so medication makes a big

01:30:27.120 difference. Medication can be very, very helpful. And I read the family where they are at on this

01:30:34.100 journey and their family values and how they're processing the information. And I listen to their

01:30:40.420 questions and concerns, and I build trust. And so some families are ready to start medication right

01:30:46.800 away. Other families have questions. I work at developing a relationship with that family,

01:30:53.140 answering their questions. And most often we do move towards medication because we know it helps.

01:31:00.860 Most of them say, I wish I started sooner.

01:31:03.300 I want to dwell on this point, Trenna, because I have to believe there are a lot of people listening

01:31:07.120 to us. Maybe not so much because I don't think my audience is quite where I'm going, but there are

01:31:11.660 going to be people who understandably come at this and are really judgmental. And their narrative is going

01:31:17.500 to be the following. These goddamn preschools trying to tell me a kid has ADHD. Maybe it's because the 1.00

01:31:24.260 preschool is just overcrowded and the people who work at the preschool are too lazy to actually let

01:31:28.660 these kids play. Let kids be kids. There's nothing wrong with a kid that's hyperactive. You just got

01:31:33.100 to give him more to do, blah, blah, blah, blah, blah, blah, blah. This is sacrilege that we would ever

01:31:37.400 give a child medication just because they're hyperactive. So that's a narrative.

01:31:42.340 Yeah, for sure.

01:31:43.060 Now, again, I don't think a lot of people, if they're sophisticated, subscribe to that because

01:31:48.000 I think a person who's sophisticated would hopefully not make a judgment like that without

01:31:51.980 understanding the fact base a little bit more. Would you agree that the best argument against

01:31:57.420 that logic, which is not an argument that says every kid should be on medication, it's an argument

01:32:02.380 that says you have to weigh the pros and the cons of being unmedicated and what the impact on your

01:32:09.180 education is going to be and the long-term success you're going to have as an adult,

01:32:14.240 as a well-adjusted adult versus the accepted risks of any medication and the potential upside it has

01:32:22.320 towards allowing that child to learn. Because again, I always like this framework you have,

01:32:27.860 which is you bring it back to what is the adaptation of the condition? What is the adaptation

01:32:32.940 of the phenotype? If it is disruptive, if this is a difference in a child's education,

01:32:39.420 if this is the difference between a kid going to college and not, if we believe that matters anymore,

01:32:44.300 or being successful in their career or not, or having pro-social relationships versus not,

01:32:51.880 then maybe we accept the risks of medication. So maybe you can articulate that more eloquently

01:32:57.420 if you have a different view, but that's kind of how I like to think about things that seem

01:33:01.100 at the surface absurd. I love all the points you brought up because it is a

01:33:05.740 risk-benefit ratio that you have to consider. You have to consider, there's risks in everything we

01:33:10.800 do. There's risks in all medications. There's risks in everything. So you have to consider both

01:33:15.040 risks and benefits. When I'm working with a family, I talk to them about the research. And we actually

01:33:22.360 have a lot of research around safety and long-term outcome and the outcome of individuals with ADHD

01:33:28.480 who are left untreated. But actually, more importantly, I get to know their child though.

01:33:33.340 So this thing, as I get to know them, I share with them the research, the safety research,

01:33:37.800 all sorts of information about the medication. But what's really important, so this is the idea

01:33:42.460 about me going and watching the child in class, me talking to the teachers, getting to know that

01:33:49.000 family more, really understanding. They come to see me for a reason. If things were great,

01:33:54.440 they wouldn't come to see me. They've come to see me for a reason. And even though the school

01:33:58.720 maybe initially was the school who said, your little guy is way too busy and you need to see

01:34:03.560 a doctor about this. But when I get to know the family, I find out, well, actually dinner is really

01:34:08.460 stressful and bedtime routine is really stressful. Everyone's in tears in the morning. And so I get

01:34:14.360 to know them and it's actually that personal part that helps them understand their child. And I come

01:34:21.160 back to self-esteem and interpersonal. Their kid is not a statistic to you.

01:34:24.560 Yes, that's exactly it. Sometimes we don't use medication. I am the first to say,

01:34:29.880 if your child doesn't need it, we're not going to use it. Although we know that medication can

01:34:34.340 make a really big difference. I've discussed this on some previous podcasts. So is Vyvanse still used?

01:34:39.560 Is Ritalin still used? Is Focalin used? I mean, what's in your toolkit in that world?

01:34:44.300 ADHD medicines, we're talking stimulants and non-stimulants. First-line treatment considered

01:34:49.440 is stimulants. Within stimulants, we have two different medications. We have one called

01:34:56.980 methylphenidate and one called amphetamine. Methylphenidate, we have many brands. That's

01:35:03.800 the Ritalin, which has been around since I believe the 1950s. We've got Ritalin, we've got Focalin,

01:35:09.880 we've got Concerta. We have lots of different methylphenidates.

01:35:13.420 What was the other one after Focalin?

01:35:15.100 Concerta. And there's many more brands. They're all different brands.

01:35:18.080 And how do they differ? Are they differing in pharmacokinetics and half-life? What separates

01:35:22.960 those three drugs, for example?

01:35:25.020 How the medication's released.

01:35:26.800 Okay. So it's just a timing of release and pharmacokinetic.

01:35:29.220 Timing of release and the mechanism of release.

01:35:30.340 But it's literally the same molecule.

01:35:31.920 Yeah. It's the same active ingredient, methylphenidate. But it's interesting,

01:35:36.040 kids respond differently to the different medications, the brands, because the release

01:35:41.600 mechanisms are different. So some kids are sensitive.

01:35:43.860 So in other words, if a kid comes in and you try one of these and you don't get the response you

01:35:49.540 want, you don't necessarily abort the entire molecule, you might switch to a different

01:35:54.800 formulation. And I only say this because I can't tell you the number of parents I have spoken with

01:36:00.180 who have said, my kid was on Ritalin. It was a disaster. When they switched to Focalin,

01:36:05.740 it got so much better.

01:36:07.400 Yeah. That's exactly right. And there's no science, unfortunately, to tell us which one's

01:36:13.120 going to work for your child. So you have to basically try a few.

01:36:16.840 Okay. And then the other one you said was just straight amphetamine?

01:36:19.780 Amphetamine. So that's Adderall, which has been around since the 1930s. And then there's,

01:36:24.200 you mentioned Vyvanse, Vyvanse, Dexedrine. So there's medications in that group.

01:36:29.120 Again, same deal. The difference between Vyvanse and Adderall is release and kinetics.

01:36:33.440 Yes. Vyvanse is actually called a prodrug. It's actually just got a little

01:36:37.720 molecule attached to it that needs to be cleaved in order for it to work. But they're all, yeah,

01:36:42.620 the same.

01:36:43.480 Again, it's very counterintuitive to people why you take a hyperactive kid and give them a

01:36:48.480 stimulant. Do you want to just give the brief overview of why that works?

01:36:52.280 So the way these medications work is they increase dopamine and norepinephrine in the synapses

01:37:01.680 between the brain cells in the parts of our brain that are important for executive functioning,

01:37:09.580 attention, inhibiting impulses. So the part of the brain, the prefrontal lobes where that all the

01:37:15.360 executive function attention happens, our brain cells have to communicate in order to see that

01:37:19.840 behavior, attention. These medications, although they're called stimulants, what they do is they

01:37:25.340 they increase the levels of dopamine and norepinephrine in these synapses, the gap between

01:37:32.660 the neurons, and they improve the electrical activity and communication between brain cells.

01:37:39.680 What are the most common side effects you caution parents about with these drugs?

01:37:43.840 So the side effects can be annoying, but they're not life-threatening. The most common one

01:37:49.420 is decrease appetite at lunchtime if you're taking a medication that lasts the whole day. So there's

01:37:57.200 medications that last three or four hours, which we used to use a lot a couple decades ago when I first

01:38:02.080 started doing this. But about 20 years ago, we started using extended release a lot more. And so

01:38:07.620 extended release is that it lasts eight hours or 10 hours for the day or 12 hours a day. And so those

01:38:13.360 medications impact your appetite at lunch. Breakfast and dinner are usually fine. There's this

01:38:18.920 chance that it impacts sleep onset, which is really important because sleep is super important, kids,

01:38:26.080 but it can impact sleep onset. And if that's a problem, we adjust the timing of the medication

01:38:31.800 in the morning. But these are generally single administration first thing in the morning drugs,

01:38:36.220 I assume? Yeah. They're really easy to use because you take it in the morning, they start to work,

01:38:41.840 the extended release will start to work within an hour, and then they're working for the majority of the

01:38:47.080 day. Then they come out of your system at the end of the day. And so tomorrow, unless you give the

01:38:53.640 medication to your child again... It's like they've never been on it.

01:38:56.320 It's like they've never been on it. What are the differences then between the Ritalin class and the

01:39:02.700 Adderall class? Do you have any suspicion one way or the other as to which is going to be more

01:39:08.100 effective if you were to prescribe Focalin versus Vyvanse? Yeah. So when I first meet a young child,

01:39:14.340 I generally start with methylphenidate. And that's what most clinicians do with little kids.

01:39:19.620 And the reason for that is that the meta-analyses show that kids tolerate methylphenidate a tiny bit

01:39:26.720 better than amphetamine. Although amphetamine is a little bit more bang for your buck when you're

01:39:32.980 treating the symptoms. That being said, no kid is a statistic. Every kid's different. So I have just

01:39:39.340 as many kids on Adderall as I have on Ritalin. Interesting.

01:39:42.480 Yeah. So I use every single brand out there, but I start with methylphenidate because it's

01:39:47.720 shown to be tolerated better. You mentioned a second ago that if your kid's been on this drug

01:39:52.540 every day for a year and experienced all these benefits, and then they come off the drug,

01:39:57.640 it's like they were never on the drug. Does that suggest that in the, I hate to use the

01:40:02.960 description this way, but I think you understand what I mean, in the drugged state, you don't get

01:40:07.340 to do behavioral therapies that also have a positive impact independent of the drug, such that if the

01:40:13.480 drug comes off, the phenotype is changing. Is that not to be expected? I want kids to be actually

01:40:20.060 practicing skills when they're on the medication. Yeah. In theory, they should be able to do a better

01:40:24.700 job. It should be easier for them to practice the skills on the medication.

01:40:28.300 Yes. So let me say a couple of things. So in theory, when they're on the medication,

01:40:32.840 it's easier for them to practice paying attention, controlling your impulses, controlling your

01:40:37.720 hyperactivity. In addition to that, this is where the behavioral parent training part comes in,

01:40:42.740 which is actually now a recommendation that every family should have, should be doing.

01:40:47.620 Training specifically for family, not just child.

01:40:50.520 Yes. Amazing how powerful parents can be in modifying the behavior of their child. So parents

01:40:57.360 undergo the training and the child might undergo some sort of therapy, regulation group. When they're

01:41:04.420 older, they undergo executive functioning coaching to learn organization and planning. So what it is,

01:41:10.880 is you are trying to develop these skills. So when we practice something over and over and over again,

01:41:18.780 not only we develop new behavioral strategies, behavioral patterns, new habits, we actually

01:41:27.160 positively impact the developing brain. That's neuroplasticity, which is one of my passions is

01:41:32.960 neuroplasticity, but we impact the brain through experience and our behaviors. So when a child has ADHD,

01:41:42.040 it is a wonderful time to practice new skills and you actually impact neural networks.

01:41:47.680 So does that mean that you're telling parents or at least holding out a hope that, hey, your kid is

01:41:55.920 seven or eight years old, we're going to put them on Ritalin. This might not be a lifetime thing.

01:42:01.560 Do you give them that hope or do you not commit to anything one way or the other?

01:42:04.900 I don't commit.

01:42:05.800 I get asked that question all the time.

01:42:07.120 Yeah.

01:42:07.540 For the types of medications I put patients on. If I put patients on a lipid lowering medication,

01:42:12.600 generally their first question, once you get through the, why should I be on this? And what are the

01:42:16.760 side effects, et cetera, is, am I going to be on this for life?

01:42:20.540 Yeah. So what I tell families, I have no crystal ball. I can't commit, but I do have many, many

01:42:26.560 patients who do eventually come off medication. Some of them, maybe they shouldn't have come off

01:42:32.420 medication. They actually should stay on their medication, but I have many patients who come off

01:42:36.020 and do really well.

01:42:37.160 Is it naive to think that because ADHD primarily impacts the prefrontal cortex that you would see

01:42:44.340 at least a subset of people when they reach their late teens as girls and mid twenties as boys,

01:42:51.220 when they reach maturation of that part of the brain, that at least a subset of them should be

01:42:56.760 able to develop potentially the skills to overcome the genetic component of this, or is that not

01:43:02.660 necessarily correlated?

01:43:03.980 No, I see a lot of kids who do find strategies to compensate and who do no longer need their

01:43:10.820 medication as teenagers or young adults. I have a lot of kids who are like that, but I think it's

01:43:16.320 really important that they start early developing strategies and new behaviors. I think that is

01:43:21.920 really important in strengthening those neural networks.

01:43:25.200 So what about the non-stimulant class of drugs here?

01:43:27.520 There are non-stimulants that we use. One is called Stratera, which also acts on norepinephrine

01:43:36.500 and increasing the norepinephrine levels in the synapses. And then there's a couple of old

01:43:43.500 blood pressure medications we use. One's called guapacine, the other one's clonidine. Those are

01:43:48.880 alpha-2 agonists. So they act in a different way with closing channels in the postsynaptic neuron.

01:43:56.660 So it's a different mechanism. But all of those medications also help with the communication

01:44:02.120 between neurons in the attention center and the brain. The difference is the non-stimulants

01:44:07.800 have to be taken every day, unlike the stimulants, in order for them to work. So meaning they're taken

01:44:14.300 every day and you need a steady state in your body.

01:44:16.900 Yeah. Do you ever mix these two or is it one or the other?

01:44:19.500 Oh, you mix them often. You do. And so often they do not have the side effects with the poor

01:44:25.780 appetite. And sometimes they can be really good with kids who have some emotional dysregulation,

01:44:32.220 impulsive emotions. So we'll often use them with a child who has a little bit of that irritability,

01:44:38.520 emotional dysregulation. And sometimes we're using both the stimulant and the non-stimulant at the same

01:44:43.660 time. Are there any medications that typically show up in kids with autism, but without ADHD?

01:44:53.520 So let's just say kids with autism plus or minus anxiety. What is the role of pharmacotherapy?

01:44:59.020 There's no medication that treats the core symptoms of autism. The core symptoms don't

01:45:03.980 require medication. It's therapy. We use medication in kids with autism to treat

01:45:09.940 target behaviors and symptoms. So we use medication for the symptoms, no matter the label. So whether

01:45:19.460 or not the child with autism has ADHD or not, we still may use an ADHD medicine. If they're

01:45:26.120 hyperactive or impulsive, we still may use it whether or not the label's there.

01:45:30.820 Got it. So you don't need the diagnosis to decide. In other words, there are kids with autism that are

01:45:36.240 going to be on medications, and it's really just a function of the symptom.

01:45:40.560 Correct. So the target symptoms we usually treat, it is the attention hyperactivity impulsivity,

01:45:45.760 where we'll be using the stimulants, or the challenges with emotional regulation,

01:45:52.240 where we'll use a non-stimulant. We may use an anxiety medicine, so a selective serotonin reuptake

01:45:58.680 inhibitor, SSRIs, such as Prozac or Zoloft. We may use that for anxious feelings. We also use that

01:46:08.360 sometimes for rigidity. So kids with autism who struggle with rigidity and transitions, it's often

01:46:14.000 anxiety related, so we'll use the SSRIs there. And then kids who have really aggressive behaviors and

01:46:22.020 may injure themselves, then we are talking about atypical antipsychotics. I'll just share with you,

01:46:27.260 right? Don't use a lot of those myself. At that point, if the child is having those difficulties,

01:46:32.520 I often am working with a psychiatrist. Again, I think it's just got to be so hard for parents to

01:46:38.480 potentially stomach putting children on psychiatric medication. But what you said earlier is sort of

01:46:45.520 interesting, right? Which is most of them are coming back after saying, I wish we did this sooner,

01:46:51.440 which I suppose would be the most affirming thing you could ever hear in that situation.

01:46:55.620 What are the things that they typically notice when they come back to you and say that? And how

01:47:00.400 long does it typically take? Well, with the stimulants, it'd be pretty quick. They're like,

01:47:05.740 we're glad we did this. And this is making a big difference. The impact of stimulants is right away.

01:47:11.680 You see the benefits right away. What do the kids say? Let's assume a child is old enough. So let's

01:47:17.340 assume you're working with a seven-year-old or a 12-year-old who can articulate their feelings.

01:47:22.720 What do they come back and say to you? They share with me that it helps them with their focus. They

01:47:28.220 feel more successful at school and they share side effects. What other side effects do they

01:47:33.440 complain of besides appetite suppression? So I will sometimes have high school students who tell me

01:47:39.840 that they feel less social and funny when they're taking their ADHD medicine. So they're a little less

01:47:47.140 impulsive or spontaneous. And so we talk about that. And I listen because it doesn't have to be

01:47:53.680 black and white, all or nothing. Our goal isn't to make someone 100% focused 100% of the time.

01:48:00.920 It's like, okay, so we want to improve focus. None of us are focused completely all the time.

01:48:06.640 So when I have people come to me with side effects, I'm like, okay, well, probably the dose is wrong,

01:48:12.520 or maybe we should change to a different medication. This one particular medication may not be the right

01:48:18.880 match for you. So we should need to change it and find one with less side effects. So I think that

01:48:23.900 the key thing is having a relationship between the doctor and the patient, lots of communication,

01:48:31.320 and the idea that if the patient is experiencing side effects, that they tell somebody so that you

01:48:38.940 can adjust, you change the dose, you change the timing, you change the brand. It's just weighing

01:48:43.880 pros and cons. You hear this phrase from time to time, which is that kids with autism have superpowers.

01:48:51.200 We might think of an example like, okay, well, Dustin Hoffman's character in Rain Man, I mean,

01:48:56.180 obviously highly, highly impaired for most of life, but clearly had a superpower. He could count cards

01:49:03.020 and toothpicks. Obviously, that's kind of the Hollywood version of that. But is there truth to this idea that

01:49:08.940 kids with autism have superpowers, or is this something that you would put more brackets

01:49:13.660 around and say, well, sometimes those kids who are in class three, where they're really impaired,

01:49:19.880 maybe there's something there, but it's a lot harder to see than the kids in class one, for example.

01:49:24.160 It is. So there is a difference class three versus class one, for sure. It's harder to see. It's

01:49:28.800 harder to see in class three. Class one, a lot of superpowers. Memory could be one of them.

01:49:34.680 Attention to detail, really good with remembering rules and following routines or a set order of

01:49:43.560 operations. There's a lot of strengths with the kids in class one.

01:49:48.280 There are a lot of famous people I won't name who have even talked about themselves as having

01:49:52.920 mild forms of autism, Asperger's. So you would almost think that it's predisposing them to some

01:49:59.840 of their greatness in the fields that they're in, often very technical fields. Is that consistent

01:50:05.200 with what you see in the children? Yes, it is.

01:50:08.100 A more of a predisposition towards engineering technical fields, STEM in general?

01:50:12.060 Yeah, definitely. With that profile, like I said, I called it a learning profile, a thinking profile.

01:50:17.400 And so things where you need a little bit more inferring, there's abstract inferring or the social piece,

01:50:24.680 it may not be their strength. But where you need to dive deep into some details, persevere,

01:50:33.380 stick with something, hyper-focus on that, you do really well. And so a lot of people, once they

01:50:39.780 find their passion as a young adult, if they find a career where they can actually dive in,

01:50:46.280 they can dive deep and do really, really well.

01:50:48.460 What do you think is kind of the most important thing you want people to understand about anxiety,

01:50:57.520 autism, ADHD, that you think is either misunderstood or not understood at all?

01:51:05.560 I think that there's a lot of overlap. I think people sometimes get stuck on the label and name.

01:51:14.080 And although there's so many positive things, we're talking about the diagnosis you need to get

01:51:20.740 resources, I think I'm concerned that people get stuck on a name and don't actually see the person

01:51:29.900 beneath that name. I think that's my key thing. I've had so many experiences where families are like,

01:51:35.740 but they told me it's autism, it has to be autism. If you think otherwise, what's wrong with the system?

01:51:42.000 And this is hard because in this field, there's a lot of gray. And so I think that's what it's about.

01:51:46.900 There's gray. It's a moving target. We've changed the names and the definitions multiple times in the last

01:51:52.300 couple of decades. They probably are going to change again. So it's for us to be flexible with our thinking

01:51:57.680 that the definitions may change again, but there are these learning styles. And so if you've met one person

01:52:05.420 with one of these names, you've met one person and it's really important to understand that person

01:52:11.380 in order to help them with leveraging their strengths and then understanding what kinds of

01:52:16.840 gaps you want to like fill and what kinds of skills you want to work on.

01:52:21.060 Trina, this has been really, really fascinating. I guess my only frustration in this discussion is the

01:52:26.460 concern that there aren't enough people like you and your colleagues out there to match what is very

01:52:34.600 likely the psychological burden of these conditions across kids today. And I'm only speaking to the

01:52:40.100 United States. So I think if you were to think about this globally, I won't attempt to make a statement

01:52:44.700 because I simply don't understand what the prevalence is or what the resources are. But I think we could

01:52:48.620 probably say in the United States that there are far more children and families that are impacted

01:52:54.640 by the AAA, then there are multidisciplinary teams that can take care of them. Are you optimistic that

01:53:01.560 10 years from now, this model is going to be different? There are going to be more people

01:53:05.560 that are going to want to come to practice this in the way like, where is the long pole in the tent?

01:53:10.840 Is it getting more people to simply go into these fields? Is it a better payer reimbursement structure

01:53:17.540 to incentivize more people around a multidisciplinary approach? What is it going to take in 10 years

01:53:24.100 to close the gap between demand and supply? I think it's both those things you mentioned.

01:53:30.060 It is definitely training more people and trying to think about how to use and recruit people who

01:53:38.100 are also going to support, for example, the developmental behavioral pediatrician or the

01:53:42.400 psychiatrist or the psychologist. For example, we need more DBPs, but we also need then like more

01:53:48.240 nurse practitioners or other allied professionals who can support the team. So it's being creative

01:53:54.480 and innovative with how you create the teams and find enough people to be on these teams. But then

01:54:01.800 how it's reimbursed and making sure there's access to these teams will be really important.

01:54:07.340 I really believe in the bridge to education as well, which is not something that is part of an insurance

01:54:13.900 I was literally just about to ask you the following question, which dovetails into that,

01:54:18.740 which is, are we thinking about this the wrong way? Are we thinking about this as something that

01:54:24.640 should be done through healthcare when maybe this should be done through education? If you had

01:54:29.640 unlimited budget, one way or the other, this has got to get paid for. So it's either going to get paid

01:54:34.180 through health insurance or it's going to get paid through systems in education. Do you think that the

01:54:39.760 burden is disproportionately on the healthcare system today and it should be a shared burden

01:54:44.560 with the education system? And I'm not saying that to be critical of the education system.

01:54:48.420 They would need the funding and the resources to do this. But is that part of the issue

01:54:52.000 is that you're always going to see these things manifested in the education system and that's where

01:54:58.160 you're going to get the most bang for your buck when you address them.

01:55:01.760 I'm going to go back to the bridge because it is, it's like the insurance, they'll say that

01:55:06.680 parts of this intervention are educational. So they're not responsible for it. And then the

01:55:12.620 educational people will say that this part is this medical thing. It's actually not interfering

01:55:18.380 with the classroom, but you need to realize to help that child move the needle, you have to have

01:55:23.840 both systems working and talking together and collaborating together if you really want to

01:55:30.380 move forward. And so it's a totally different system, but I really believe in bridging education,

01:55:37.200 mental health, and medical if you want to make an impact on child well-being and health.

01:55:44.480 I'm really hopeful that this message spreads and that we see more and more of this type of 0.65

01:55:48.720 integrative approach because it really makes sense. So thank you so much for your time and

01:55:52.640 appreciate you coming out here.

01:55:53.980 Thank you.

01:55:54.300 Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com forward

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The Peter Attia Drive - January 06, 2025

#330 – Autism, ADHD, and Anxiety： Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children ｜ Trenna Sutcliffe, M.D.

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