#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.

Hey everyone. Welcome to the Drive Podcast. I'm your host Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness and we've established a great team of analysts to make this happen. It is extremely important important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return we offer exclusive member only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peterattiamd.com subscribe My guest this week is Dr. Trena Sutcliffe. Trena is a developmental behavioral pediatrician and the founder and medical director of the Sutcliffe Clinic in the Bay Area, which partners with patients and their families to evaluate and provide supportive care for children dealing with issues such as behavioral changes, developmental differences and school struggles. In my conversation with Trena, we explore her journey into developmental and behavioral pediatrics. In fact, she was the first person to be practicing under this designation at Stanford when she arrived about 20 years ago. This includes her background in genetics, pediatric neurology, and her current work in leading multidisciplinary teams around the care of children with autism, ADHD and anxiety. We spoke about the diagnostic processes for autism, ADHD and anxiety, which she calls the three A's, discussing how these behavioral diagnoses are made based on clinical traits and the criteria depending on the age of a child. We focus on the overlap between the three as and how comorbidities are common in children with each of these conditions. Trena emphasizes the importance of a personalized treatment plan to consider the whole child, including their environment at home and school. We talk about the changing diagnostic criteria for autism between the DSM 4 and the DSM 5 and what some of the drivers might be for the increase in the prevalence of autism today. This is a very hotly discussed topic. Trena provides a very thorough discussion of what the factors are that may be contributing to this. We discuss the various therapies, including Applied Behavioral Analysis or ABA for autism, behavioral interventions and parental training for adhd. We cover pharmacologic options, particularly for ADHD and anxiety, including the use of stimulants, non stimulants, and SSRIs. Trena explains how these medications are used alongside behavioral interventions to help children manage symptoms and improve their daily lives. And we talk about the challenges families face in accessing care, particularly outside of major urban areas, and the importance of bridging health care and education to create a more holistic approach to support children with these developmental conditions. So without further delay, please enjoy my conversation with Dr. Trena Sutcliffe. Well, Trena, thank you so much for coming all the way out to Austin. Really nice to meet with you in person. I've heard a lot of things about you from various colleagues in the Bay Area. And frankly, this is just a topic that I think a lot of people are interested in. Obviously many of them parents. But I just think people in general are kind of interested. And so maybe just before we jump into it, let's spend just a couple of minutes on your background so people understand who you are and why I wanted to spend so much time with you. So you trained in pediatrics, developmental and behavioral. Well, let me not try to summarize what you've done. Tell me what you've done.

Okay. Well, initially, I did an undergrad and master's degree in genetics and then went on to medical school. After medical school, I went on and did a residency in pediatrics, but ultimately wanted to do developmental behavioral pediatrics for numerous reasons, because it just was a really good fit with my interests and passions. So I did actually a year in pediatric neurology and then a full fellowship in developmental behavioral pediatrics before moving to California.

Your interests today primarily revolve around behavioral therapy for three things that we're gonna spend quite a bit of time talking about. I won't commit to the order yet. Cause that'll come out of our discussion. But somewhere along the way, we're gonna talk about autism, we're gonna talk about adhd, and we're gonna talk about anxiety. So coming at this through the lens of what you do today, which is running a really large, successful multidisciplinary clinic, I assume this is just for children. So this is up to 18 years old, basically. Is your patient population correct? Let's start by just getting some of the diagnostic criteria straight. I think that in general, most people listening to us have a gestalt for what each of those things are. But I think it would be helpful to maybe understand clinically how you look at each of those. So let's start with anxiety.

How I look at it clinically.

Yeah. And how is it defined? How clear are the diagnostic criteria? What does the DSM 5 say about it and how does a practicing clinician use that or maybe modify that in the way that they try to come up with a diagnosis?

So with all of these diagnoses, anxiety, adhd, autism, they're behavioral, clinical diagnoses. So it's based on checklists of a number of traits and characteristics. Now you need to be working with a clinician, a physician who has enough experience diagnosing these conditions, trained in these conditions, but essentially that person needs to be an expert on what the clinical picture looks like, because there's no biomarkers for any of these conditions. That's the key thing. There are no blood tests, there are no brain scans to say who has anxiety, who has adhd, who has autism. I have families come to me all the time and I explain to them I have these clinical boxes and labels and diagnoses in my clinic. And these boxes and labels are man made. We create these lists of criteria, but neurobiology in the brain is much more complex than these boxes. So the key thing is to have a clinician who looks at the, and for me, a child and looking at their traits at home, at school, in multiple environments, collecting data through talking to parents, history, getting information from people other than the parents. So that's using rating forms or talking to teachers and therapists. Ideally we get to see the child in their real life environment, so maybe even observing them in a real life place like school, and then doing assessment in the clinic to collect information about them. And with that, that clinician decides whether or not they meet diagnostic criteria, a list of traits or characteristics described in a book called the dsm. And then we decide whether that child meets that criteria. But one of the key things is about whether or not those traits are creating impairment. And that's a key criteria for any of these diagnoses. For example, anxiety. We all have feelings of anxiety. Anxiety is actually a very appropriate, normal feeling that we should all have. But it's all about how much impairment is it creating? How does it impact function and impact someone doing their job? And for a child, their job is to learn and go to school, make friends, practice communicating and interacting with other peers, and be a positive contributor in their community, which is school. So it's about how these traits impact their function in that job.

What would you say is the youngest age that each of those could be diagnosed? And I do want to talk a little bit about what the layers of diagnostic criteria are, but just starting at the first question, which is if a parent says, hey, I think my child has such and such, I really want to get a workup. Is there an age beneath which you would say this might not be a good use of time and energy?

So for autism, although the typical age for diagnosis is more like three or four, we can confidently make that diagnosis as young as 18 months of age. And I'll be honest, in the last 20 years there's been one or two cases where I've made it at 15 months of age because it was very significant and obvious. Most often at that young age, we do wait a few more months to watch how the child develops because kids are moving target. But with autism it can be 18 months, 2 years of age, although half of the cases of autism are diagnosed over six. With ADHD you can make a diagnosis as young as four years of age. But again, I'll just tell you from my clinical experience, I rarely jump onto the diagnosis with a four or five year old because there's still a moving target. Although I may start interventions, behavioral interventions and parenting support. But there are a lot of four year olds who are pretty busy, so I generally wait closer to school age, although technically you can make it as young as four.

So that would be for most kids. When you say school, you don't mean preschool, you mean actual kindergarten. Five to six, five to six.

I think a lot of people will wait till five or six to really see how that child is evolving. Although technically you could make it younger. And then with anxiety, there's separation anxiety. There's something called selective mutism in young kids in preschoolers. So anxiety, there's many different types of anxiety, but there's definitely anxiety conditions in preschoolers.

Let's talk a little bit more about that. I don't know much about anxiety and I'm guessing most people listening have a sort of hand waving sense of what it means. But you said separation anxiety as an example. Anyone who's been a parent can appreciate moments of that. 99% sure our puppy has separation anxiety. What are some of the other types of anxiety and how do you look to spot those in kids?

So again, just to emphasize, anxiety is actually a normal emotion that we should all have. So it's all about whether it's creating enough impairment. So in the anxiety bucket, there's multiple different types. So someone may have generalized anxiety where? That's exactly it. It's generalized. It's seen in multiple places as pretty pervasive. People can have specific phobias towards dogs or spiders or other things. I mentioned separation anxiety, so that is a condition. And again, yes, many toddlers have separation anxiety. That's very normal. It's about how severe and significant the anxiety is and how pervasive it is and whether it is impacting function. So when it's impacting the ability for a child to go to childcare or preschool, then it's something we need to help. Other types of anxiety, there's something called selective mutism. Children who are able to speak very well and speak well at home or with familiar adults, but do not speak and are mute outside that familiar environment. There's also obsessive compulsive disorder, where people have obsessive thoughts or compulsive behaviors. So there's many types of anxiety conditions out there, and children have these.

You've reiterated it twice now, which tells me how important it is. It really has to come down to this impairment thing.

It does.

All of us could probably read through the DSM 5 and place ourselves in each of these diagnostic buckets. I know I can. I've done that exercise and turns out I could make the case. I have everything. But the truth of it is, what I try to ask is, which is maladaptive, which is mostly giving me the negative response that is impacting relationships or work or these other things. I like that framework for kids, because if you think to yourself, oh, my kid has adhd, but they're doing well in school, they're progressing in reading, writing, arithmetic, they enjoy playing sports. Yeah, maybe they're a little bit more rambunctious, but they have friends. How would you help a parent sort of navigate that if they came to you and said, I think my son or my daughter has adhd? Like, what are kind of the impairment style questions you would be asking to paint the contours of this condition? Even if you acknowledge that that kid's got a lot of energy, those are.

Great questions because it is definitely a spectrum. There's a bell curve. Yeah, we're all on a bell curve for all of these diagnoses. There's a bell curve. And so it's when does it become leaving the average range, the typical profile, and over into a. What we call a disorder. And actually, I don't like to use the word disorder for these conditions either because I think they're just learning differences and thinking differences as well. But when does it become a disorder? So questions around impairment. So for me, one of the number one things I talk about with families is self esteem. How is it impacting that child's self concept, how they see themselves? How is it impacting their relationships with peers? That's another key One. So does it impact social interactions? Does it impact how they connect with peers? Does it impact the feedback they're getting from peers? How does it impact their ability to learn and access learning opportunities at school or on the playground? So are these traits impacting their ability to fully engage in learning, be successful, show their potential? The self esteem thing is very important to me though. So for a child who has a biologic condition, these are all biologic. There's neurochemicals, there's genetics involved, These are biologic conditions. And for a child to have a biologic condition and be in class and then feel bad because they are worried they're not doing well enough and they're getting a lot of negative feedback from teachers and peers, not because those people are trying to be mean or negative, but they have to constantly remind that child because that child is forgetting things, losing things. Forgot to put their name on the piece of paper, completely automatically losing things. Yeah, losing, yeah. So it's losing, forgetting. It's not completing tasks, it's not sustaining attention in a conversation, it's actually avoiding tasks that require a lot of sustained attention. So there's a lot of these traits where it's impacting this child's ability to be successful day to day at school.

How do you assess self esteem? What questions are you asking the child? When you actually get to sit down with the child to determine that? And is there anything you can glean on that dimension from speaking with anybody other than the child?

Yeah, you speak to the child and you do talk to others, both of those things. When you talk to the child, there's multiple different ways of doing it. Not always easy to get the answer. With younger children, we sometimes use approaches where we actually are talking about a third person. So there's a number of different techniques where you are working with a child. Of course you're building relationship rapport with a child. There needs to be trust. But there's a number of ways that we assess it where we actually may talk to them about another child so that you have another third person. Because it's sometimes easier to talk about a third person than yourself. So talking about situations, about how another child would feel at school, or why does another child feel uncomfortable at school, or why does a child come home crying some days? And then you hear their stories. So when the children talk about that, they actually relate to their own situations and they start to say like, well, Johnny came home from school crying because nobody wants to play with him because he always messes up rules to the game.

What is the age window in which you can utilize that technique.

It's mostly primary elementary school age. So I feel like by the time I get to a second grader, they are second, third, fourth, fifth. They're able to share these stories about.

Other people, you mean? Yeah. Interesting.

Yeah. When they're older, they'll talk about themselves. It's hard to reflect on your own feelings and thoughts. For a child to identify their own emotions and the why behind their emotions is challenging.

So you've, in that description, actually made a pretty clear, I think, case for some of the traits that are showing up in ADHD and in anxiety, all the different variants of it. Let's talk a little bit more about autism now. Of course, it was referred to as asd. Right. Autism spectrum.

Autism spectrum disorder.

Will park for a moment the use of the word disorder and maybe come back to that a little bit. But tell me today, how is the diagnosis of autism made? Because I think when many people think of autism, if they're old enough, they might think a rain Man. You're going to think of somebody who, in a very short interaction, a non clinician would go, oh, that person is not neurotypical. That person clearly has something about them that's quirky and very different. And you might think of even more extreme examples of children that are non verbal and things of that nature. But again, given the nature of this and the fact that it's a spectrum, that must make it even more challenging to find the diagnosis correct.

Very, very. I have so much to say about autism, the diagnosis and how we make it and how it's changed so much over the years. So autism spectrum. So first it's a spectrum, huge spectrum of what this means. When we talk about autism spectrum, it goes from what people remember it from decades ago as from nonverbal, very little communication skills, being somewhat isolated, not interacting with other people, mannerisms such as flapping your hands. That's sort of a classic description that we do remember from over the last couple decades. Nowadays, many children who have a lot of speech and language skills, who do communicate a lot, but struggle with the social communication that we have with each other, who have many, many strengths, but do struggle with social skills and do have some restricted interests of repetitive behaviors, they also qualify under this umbrella term called Autism Spectrum disorder. And this term, Autism Spectrum disorder, that term came out in 2013 with the DSM 5. So how we diagnose it is based on, again, clinical traits, but the definition and the checklist of those traits have actually changed many times over the last few decades. So currently it is. You work with an expert who has a lot of experience with autism, and they do an analysis of someone's behavior in the two areas that we look at, social communication skills. And the other is the repetitive behaviors, restricted interest. So for social communication skills, our current diagnostic criteria requires that a patient has differences in three specific areas. One is their social reciprocity. So this is the back and forth of social interactions. It's how do you initiate socially, how do you respond socially? The second area is related to nonverbal communication skills. So it's how someone uses their nonverbal communication, eye contact, gestures, as well as how they understand and interpret somebody else's nonverbal communication. And then the third area is related to how they understand relationships. So it's about building friendships, playing with peers, how they understand the social context of being in a group. So those are the three key areas when it comes to the social communication piece. And in order to get the diagnosis, you do have to have differences in all those three areas.

Is this something that is done during one assessment or is this something that's done over repeated assessments?

Depends on the level of severity in the child. So first of all, it's important that whoever's doing the assessment really understands that child.

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

It can be a physician or it can be a psychologist. That's generally who does it. So physician would either be a developmental behavioral pediatrician or a psychiatrist. That's most often. Occasionally it's a pediatric neurologist or somebody else with some sort of similar background and training, but generally DBP or psychiatrist. And if it's not a physician, then it's a psychologist that usually does the assessment. And so the assessment could be multiple things. There's no gold standard. Like, the assessment has to include certain components. But again, like as I mentioned, it's important that the clinician get to know the child. I think it's important to understand the child's profile. The label is only one piece of it. If someone tells me their child has autism, I actually really don't know much about their child. Say more because you tell me your child has autism. I really don't know what your child is like. If someone tells me that on the street, then we come up with treatment plans for, like, a child with autism. It's like, well, there's a saying, you've met one child with autism, you've met one child with autism. And so to really make a difference with the treatment plan. You need to understand that profile of that child, that child's strengths and challenges. And so for me, there's multiple goals with the assessment. One part of the assessment is to make a diagnosis, because the diagnosis can be a tool to help the adults around that child better understand that child. It gives some sort of structure of, like, how to approach that child and leverage their strengths and work on skill building. It can help get resources at school or through insurance. So the diagnosis is a tool, however, to really make a difference. You want to understand what about that child is unique and different and how do you support that child? So you were asking, how do you do an assessment? So when it is a more significant case with significant impairments, we frequently can make the diagnosis. I'll just be honest. You can make it pretty quickly. You should take a good history. You should definitely meet with the child, work with the child in the clinic. But there are many children where a trained clinician can do that diagnosis pretty quickly. In a child with very significant autism, it'd be obvious to you if you were in a restaurant, you saw someone with autism. It's obvious to many people. But for children who have milder symptoms, it is really important that they probably use multiple visits to see the child on multiple days. That different types of assessments are done directly with the child in addition to taking history with the parents and in addition to collecting information from other people involved in that child's life, such as teachers or therapists. It's important to get different perspectives.

So you mentioned that the diagnosis in probably more severe cases can be made earlier and earlier in life. Sounds like sweet spot is three to four years of age. But then you said half of the kids are diagnosed above six.

Yes.

So is that something that is a relatively recent phenomenon of the past decade, since the DSM 5 broadened the inclusion criteria? Or was that even true in the 70s and 80s?

It's complicated. I'll say. It has a lot to do with the new diagnostic criteria. So before 2013, we had Asperger's syndrome. We don't use that diagnostic label anymore. And we also had something called PDD nos, Pervasive Developmental Disorder. Not otherwise specified. A mouthful. And PDD NOS was a term we used when it had similarities to autistic disorder, because all three of those names were under the umbrella of autism. And so there were a lot of kids who received this PDD NOS because they were like, something's different, something's different. They're sprinkled with bits of autism, but they didn't quite meet all the criteria. When you didn't meet all the criteria, you got PDD nos. And then there was Asperger's syndrome, which generally described an individual who had good cognitive skills, average or high cognitive skills, intellectual skills, they had a lot of speech and language skills. They actually had huge vocabulary. But again, their social reciprocity, back and forth, conversation, picking up on social cues, that was atypical. And they also had a lot of restricted interests. They would have things they were really interested in, but then they would dive deep into those things. So in 2013, with the DSM 5, we put all of that together under Autism Spectrum Disorder. And so now the kids who have the more clear cut, very traditional autistic disorder, they're picked up at two years of age or two and a half, three years of age. And it's the kids who have the stronger cognitive skills. They have speech and language present, they're picked up later, by the way. Nowadays, with the new diagnostic criteria, language impairment may or may not be present in the diagnosis. When you give the diagnosis of Autism Spectrum disorder, you also have to clarify whether there is intellectual disability. So with or without intellectual disability. And then we say with or without language impairment. With all of these changes, the spectrum, it's very broad.

Now, this is a question I'm sure you get asked all the time. So the CDC said in the year 2001, in roughly 200 kids, 150 to 200 kids had autism. Now, of course, that's pre this change of the DSM 5. So we can only take that to mean that those were the kids in that bucket of more extreme autism that did not include the PDD nos. Was that what the other one was called? Yeah, and Asperger's. But if you look at the data, up until prior to that change, the last year, prior to that change in 2012, it was down from 1 in 150 to 1 in 69. So in other words, there was something that was increasing the prevalence or diagnosis by about a factor of 2. Then we get the change in the DSM and today we're at 1 in 36. So it begs the question, what is it that is driving the increase in the prevalence of asd? Notwithstanding that, there has also been a larger net cast around it.

I can't believe it's 1 in 36. Because I've been doing this for 25 years. I can never keep track of the numbers. Every time I go to an annual meeting, the number changes and it is 1 in 36.

Now, again, that's what the CDC said in 2020. So I'm going to go with whatever numbers you take. I'll believe your numbers more than mine.

The point being that the numbers have changed drastically. And yes, people will say part of it is because the definitions change. There's more awareness, there's more resources, there's more clinicians making the diagnosis. But people in the field believe that those changes don't explain the drastic changes in the numbers. And there has to be something else involved. And there is a lot of research in this area looking at the impact of the environment and epigenetics and what roles those two things have in increasing the rate of autism in our population.

If you're at a dinner party and you get cornered and everybody wants to talk about this, how are you walking people through this? What are you saying? Let's put the diagnostic criteria aside. Let's put the keys under the lamppost aside, meaning wherever there's more attention, you're gonna see more things. What are some of the environmental things that you think could be amplifying this?

There is thoughts around pollution, maternal infection, prolonged fever during pregnancy, the health of the placenta, stress, parental age. There is a lot of environmental factors that have been implic. But what I want to say is just to take a step back first, just kind of talk about the cause of autism, the genetics and the environmental piece. Just to make it really clear, the word autism describes a constellation of symptoms. There are many, many causes for autism. There isn't a single cause. What causes autism is very complex and we actually have more questions than answers. It's felt, though, that it is like a ten hit model, meaning we don't know that the number's ten, but the.

Idea that there's more, it's not a two hit model.

There's many factors involved, and it's almost felt like it's gene, gene, gene, environment, environment, environment. And then now it's like epigenetics, epigenetics, epigenetics. And so it's multiple hits. And the order of the hits and the timing of the hits are also felt to be very important.

Let's start with the genetic piece. We've had a number of folks on the podcast over time, so the listeners are probably familiar with what we mean by the heritability of something. But maybe just for folks that need to brush up on that, we would talk about the heritability of a condition, whether it be depression, whether it be schizophrenia, whether it be bipolar disorder is largely determined by you have identical twins separated at birth, raised in completely different environments, what is effectively the probability that they're both going to come down with the same psychiatric condition? And that's unfortunately. Fortunately, that's the purest way we can get at what the genetic heritability is of something when you don't know what the genes are or when there are so many genes. And it's very complicated. And my recollection is that the heritability of autism is quite high. I don't remember the number. Can you enlighten me?

It'll be anywhere from 70% to 98%, depending again, on the definitions used at the time, but it's well over 90%.

Wow. I didn't know it was that high. I thought it was in the 80s, which is still very high. Am I also correct in my recollection that the heritability of autism is higher than it is for any other condition in the dsm?

I believe so, yeah.

In other words, even schizophrenia, even bipolar, even depression and things that we know have very strong genetic components, none are as high as it is for autism.

Correct. There's definite genetic component to this. But may I say. So it's not one gene.

Yeah, I was just gonna say. So let's make sure people understand.

It is not one gene. It is multiple genes. So anybody with autism, they have multiple genes that have been changed. So there's multiple genetic changes in anybody with autism. And the other thing is, every person who has autism, they probably have a different group of genes that have been changed. It's actually hundreds, and some people say up to like a thousand genes have been associated.

Yeah. So I think autism maybe a way that I would explain this. And please correct me if you don't like this analogy. I liken it to cancer with a fundamental difference. So hear me out for a second and feel free to shoot this down. Cancer is mostly about somatic mutations and not germline mutations. Meaning most of the time, when a person gets cancer, it is not based on genes that they were born with. It's based on genes that were at one point normal, that have since acquired mutations in their mutated state. They no longer function normally. The person develops cancer. So this complicates my analogy, because only about 5% of cancers arrive from germline mutations, whereas the genes that are implicated in autism are indeed germline. You're born with them. However, the point I want to really make is comparing the somatic mutations of cancer to the germline mutations of autism. And the point I'm trying to make is that when you've met a woman with breast cancer, you've met a woman with breast cancer, you're not going to find too many women that look the same with breast cancer. And that's really why gene therapy hasn't panned out for most cancers, because to say that a person has breast cancer tells you some stuff. You could dig a little deeper and say, well, it's estrogen positive, it's progesterone positive, it's HER2NEU positive. But still, why wouldn't they all respond the same? Well, it's because they have many different underlying genetic changes. Furthermore, they have completely different immune responses in terms of what their tumor looks like. And so the way I try to think about it myself is if you see a hundred kids with autism, and let's just pick a number that's somewhat conservative, we would say that that's 85 to 90% heritable. It simply means that the underlying genes for each of them were inherited, but they might have nothing to do with each other across all of those children, just as we would say, all of the women who have breast cancer have acquired mutations that gave them breast cancer. But they could all be very different.

I agree.

Again, I could poke holes in that analogy, but I think that's maybe an easier way to think about it, because polygenic things are harder to wrap our heads around, especially when we don't know what all the genes are.

Yeah, so we don't know all the genes. We know that there is this genetic component. It's like each child with autism has a different fingerprint with their genetic makeup. And so there's these genetic changes. But some of the hits I mentioned are environmental. So there is research to show maternal stress, pollution, maternal diet, parental age. These things also are associated with autism. And again, there's a long list. So there's a long list of things that are associated, but none of them alone. Each one alone is not the key to autism. It's the combination.

The thing I'm still struggling with is let's take another example that I think we can all point reasonably at. Fifty years ago, the incidence of type 2 diabetes was in the ballpark of 1.5 to 2%. 1.5 to 2% of people in the United States had type 2 diabetes. Today we're God, I haven't looked in a while, but it's over 10%. And I'm talking clear type 2 diabetes. 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 seven fold increase in a condition over the course of one generation. So then the question of what are the environmental triggers? It would be very difficult to explain that just genetically, that there's been some genetic change. We might have genetic susceptibilities, we might have genetic manifestations. But the thing of it, something must have changed. And I think most people would point to our food environment as the leading thing that has driven that change, because the change in the food environment in 50 years is dramatic. So when we apply the same logic to autism, do we see big enough changes in these environmental triggers, even just over the last 20 years or 25 years, to say, okay, 25 years ago, kids were born with the same genetic predisposition. There can't be that much genetic drift. Unless we believe we are seeing more people pair together to combine four genes or genetic combinations that are producing this phenotype more than we saw before. We can come back to that. I'd love to hear your thoughts on that. But let's put that aside for a moment. If we're saying that whatever epigenetic change is happening is triggered by something in the environment, and we're talking about if paternal age is going up, if maternal stress is going up, if maternal nutrition is getting worse, if environmental toxins, microplastics are all over, everybody's talking about those things, heavy metals, whatever it is. I would love to go into a little bit more detail and get your thoughts on how those things are changing. And we have to talk about vaccines. Of course there's going to be a subset of people here, I think, who understandably would think, hey, what about vaccines? Haven't we changed the way we vaccinate kids? Is that participating in it? Now you mentioned that this is an in utero genetic condition. If that's the case, then childhood vaccines might be less responsible than some might think. But I'd just like to hear you riff on all of this stuff because before we get into the what to do, I still think there's a lot of people asking, how did we get here?

I wish I had all the answers. I don't. I think it's complex. There have been changes in. You talk about diet, pollution, toxin exposure. I think that's one piece of it. It is one piece. With epigenetics, as you know, it can be epigenetic changes, which, just to clarify for everybody, the DNA sequence is not changed. It's about tags on the DNA that can change the expression of genes or proteins called histones that are Changed that end up resulting in changed gene expression. But the changed gene expression can actually be inherited or passed through generations as well.

Yeah, I was going to ask you about that. Do we know that to be a fact that the epigenome is being transmitted?

I think it's controversial. I think it's controversial, but there is some thought about that, about the idea of the germ cells in a fetus, in a grandparent, being exposed to smoking, toxins, changes in food, how that grandparent exposure can actually change methylation in the germ cells of a parent who's a fetus, who then that germ cell goes on to be a child with autism. I don't know if that made sense. It was sort of confusing.

It makes a ton of sense to me because I think about this problem night and day. I do want to make sure the listeners understand that first of all, this is not established, not at all. And I want to make sure they understand what we're saying. So let's explain it one more time. We have these four things that make up DNA, your C, G, A and T. And that is the code. That is the code of life. But on the backbone of those things, you can put little methyl groups, which is just a little carbon with three hydrogens, and that's called epigenetics. And by the way, we're all born with methylated groups all over our epigenome, back of the genome over life. No, that changes. So we know that simply aging changes methylation. But we believe that there is differential methylation in individuals in response to all the things that you've talked about. And we know that methylation controls gene expression. In fact, methylation is probably the single most important thing that controls differential gene expression in different tissues. So the question, the jugular question, is if you have a methylation pattern, can you pass that on to your fetus? And what you said a minute ago is even more remarkable, which is, would that child, when they develop, pass that methylation pattern on to their fetus? At that point, methylation, epigenetics would start to become genetic, right? It starts to become a part of the germline. So, I mean, this is an answerable question, by the way, in my book, when I think of things that we should know the answer to in a decade, I'm going to put this in the list of things that we should know the answer to just based on the fact that we will have enough longitudinal data, I think, to be able to get at this. I don't know if you're as optimistic.

As me, I am. The key thing is that we do know the environment impacts the methylation and the epigenetics. So it's the idea of crossing generations. It's the idea of the methylation in a germ cell is altered or changed because of some sort of environmental exposure in again that parent or grandparent.

And so in that sense the child is now susceptible to two things, the germline that they inherit from both parents and as a fetus, the methylation impact that occurs as a result of any of these other factors you've discussed. Who are the people that are studying this most closely? Is this in the purview of the geneticists? Is this in the purview of the epidemiologists? Who are the people that are most working at this? Because again, as a general rule, I always think that it's very foolhardy to work on a problem, an epidemic, without understanding the causal nature of the epidemic. I use the example of heart therapy, changed the face of HIV forever. One of the greatest success stories of infectious disease medicine. But it was all predicated on understanding what the cause was. If you didn't understand that HIV was destroying CD4 cells, you didn't have a prayer of developing that therapy. And do you ever worry that, what's to say this isn't gonna get to be 1 in 3 kids in 30 years? And are there enough people like you that are going to be able to help parents and help families and help children with that? I don't wanna sound alarmist, but I worry when we have an epidemic potentially and we don't have a great sense of causality, that's profound.

And I'm thinking about a number of different things. One I'm thinking about, cause you were talking about this one in three and.

I'm just throwing that out as hey, what if this trend continues?

Right? Yeah. And so one of the issues though is how we define the condition. That's the thing. So there is still that. Although I believe that there is this piece with genetics and the environment and how we are evolving and there's this phenotype, this phenotype where there is differences in social communication skills and repetitive behaviors of restricted interest. This phenotype, which is on a huge spectrum as well. I just want to make sure this is the thing when we are talking about these numbers like 1 in 36 and this number continues to increase. It's not just the kids who are like non verbal autism, it's this really wide phenotype is increasing. And so it is important we Understand the cause of why this phenotype is increasing and then what should we or should not be doing about that?

What do you know about the change in the frequency or the prevalence of. Let's pick one subset of that, which is the nonverbal or child that is so impaired that I could diagnose them or a parent could diagnose them. Do we know if that has remained relatively constant over the last 25 years, despite the change in diagnostic criteria?

I believe there's an increase in that number as well. But the numbers that are put out there, the really profound numbers, actually describe the entire spectrum and they don't actually subdivide into the different parts of the spectrum.

Do you have a ballpark idea? So if the overall diagnosis of autism has increased fivefold in the last 20 years, has that more severe part gone up by 50%, by a hundred percent? I mean, what do you think it is or what do you know it is.

So we subdivide autism spectrum into three buckets. Level one, level two, level three. So the more significantly impaired children would fall into level three, where they require very substantial support. There are very few research studies that actually look into these sub buckets. And I have to be honest, I'm not sure clinicians are always great at identifying kids in the sub buckets either. Like, you and I are talking about a very specific profile that should be very obvious to identify. But there's other kids in sub bucket three that are sometimes put in sub bucket two, depending on what clinician they see.

And I'm going to guess that sub bucket three is not the totality of the children that were called autistic prior to 2013. Is that a safe assumption?

Yes.

So you can't even say, assuming the data existed, and it sounds like they don't, we can't just say what was the prevalence of autism in the DSM 4 and how does it compare to ASD sub 3 today? That wouldn't even be a meaningful comparison.

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

But even if they did, it wouldn't be apples to apples.

It's not okay. By the way, one of the reasons they actually went from the Asperger syndrome, pdd, nos, autistic disorder. Cause that was actually quite controversial when they actually decided to put all three of those things under one umbrella called autism spectrum was because clinicians did a really poor job of deciding which bucket you were in, which bucket you were in, so you would have a child and One clinician would call it Asperger's syndrome, another person would call it autistic disorder, another person would call it PDD nos. So they decided, okay, rather than having these three names, let's put it all under autism spectrum. So then they put it under autism spectrum, but then they have level one, level two, level three. But I would still say that clinicians still struggle sometimes where there is a little bit of overlap. It's not always clear.

Now, if you go back to DSM 4, when, as you mentioned, physicians are struggling to know which of these buckets to put them into. As an outsider looking in, my first question is, does it matter in terms of treatment and resources? Does it matter more in terms of outcomes and support? There must be a reason why people cared about that. In other words, if you had a child in the year 2000 who one clinician said, this kid has Asperger's syndrome, and another person said, no, they're autistic, was that going to make a material difference in the type of support that they got and most importantly, the type of person they were going to turn into? Like, were they going to reach their full potential in their differential capacity?

So it did make a difference with respect to resources. Children with Asperger's syndrome frequently did not get support or support covered. You needed autistic disorder to get support.

And what about PDD nos? Waist bucket?

Yeah, people didn't know what to do with that. So if by putting everything under autism, then it's like, okay, if you have autism, you should receive services. It was a tool. The label's a tool to understand and get resources. Now we have level one, level two, level three. Now, level one is, it says requires support. Level two is requires substantial support. Level three is require very substantial support. My concern is that again, when a child is level one, they don't always get the support they need because they have so many strengths. So kids in level one, frequently, they have good cognitive skills, they have a lot of language skills, they struggle with some social skills, and they may have some difficulties with executive functioning and coping skills at times, but again, it's considered mild. And a lot of those kids don't get support. And I think that's unfortunate because they also are the kids that respond to intervention so well. If they get a little coaching on how do you cope with distress, how do you cope with change, how do you practice some social skills? Not that they have to change. We don't need to change everything about them, but giving them a little bit of support about how to again be adaptive in a community, giving that support goes a long way with that group. But frequently they don't get the support because they're called level one.

Help me understand the natural history of those kids. Back in the 70s and 80s, back in the 70s and 80s,. When you and I were kids, nobody thought anything of those kids, right? Certainly weren't going to get labeled with autism. They certainly weren't going to show up with in school programs to help them with their social skills and with their communication skills. As you pointed out, they're intellectually not impaired. So it's not like they're going to struggle in school, but there's clearly something that they're struggling with. Obviously this hasn't been studied, but I'm very curious, based on your experience and your judgment, are those people that just went on to pick careers where they didn't have to interact with people, but they could still do challenging cognitive work, what was the natural history of them? There are clearly a lot of them.

There are. There are a lot of them. And I think they found a path that made sense to them. They obviously learned what their strengths were. And their strengths may have been around memory, detail oriented, following rules that are black and white. They may have had really wonderful cognitive skills in certain areas that were less around inferring and social skills and more concrete. And yeah, we don't have studies to say this for sure, but my guess is they have lived happy, successful lives. A lot of them, some of them doing things that they enjoy doing, are passionate about. They probably have found ways to not engage in large social settings. But there's a lot of careers out there that are a good match and they also have relationships and marriages. I just want to emphasize that people with autism get married.

I just think there's zero chance that there aren't thousands, if not tens of thousands of these people listening to us right now because they're adults today. And I wonder if they're listening to some of this and they're saying this resonates. I get that. When I was a kid, I was hyper focused on this stuff. I wasn't interested in a whole bunch of stuff. It was a little harder for me to interact with other kids and things like that. And yet I found my path and here I am today.

So I talk to parents all the time about this because I evaluate children. I evaluate children for autism or adhd. And very often when I'm evaluating the child, at some point while I develop this relationship with the family, the parents say, gosh, so much of my child is in me, as you are describing my child and my child's strengths and challenges. And I see me, and this is exactly what I went through when I was young. And then they share how hard it was, and they say, gosh, no one understood me, or I felt bad because I was misunderstood, or I thought it was my fault I didn't try hard enough. So I have to say it can be validating for an adult to learn that it wasn't their fault and this is part of their wiring. I have many, many parents who ask me, should I go get assessed now?

What do you say?

I ask questions. I think information is power. I think it's good for them to be thinking about it, whether or not they go on to actually get assessed. With the autism piece, often they don't. With the ADHD piece, they often do because they realize actually their ADHD traits are impacting their function and success at their job. So sometimes they will actually go to a psychiatrist to get an assessment. But I do share with them the genetics and the family history. So what do I say? I validate. I say, yes, you're telling me that growing up you had many traits that today we would classify under one of these diagnoses. You're right. It is possible because these things do run in families and there is a highly genetic component. And I think sometimes just that conversation can be therapeutic itself in that someone feeling validated and they have that aha moment, like, okay, this explains a lot. And then they can feel good as well because they're like, okay, this explains a lot. And I've gone on and I currently have my family and I'm doing well in many parts of my life, but it helps them also understand, like, ah, but now I understand why sometimes I do have these challenges at work or with my spouse. It's interesting, just sometimes having a perspective where now you can see your challenges through a different lens sometimes helps a person just actually now think about, okay, now I can adjust or understand the triggers or can reflect to think about how do I want to respond the next time. So I think, again, that information's empowering. Even if they don't ever go to therapy or do anything else, just actually starting to become informed about it can help.

Yeah, And I would imagine it helps them a lot with their child because they're seeing both. Hey, my child has this diagnosis that now partially explains, you know, the challenges we might be having, et cetera, but at the same time, because I can empathize with that child if I've experienced it, it makes you a better parent. So everything you said makes a great case for widening the diagnostic envelope. Because if we go back 40 years, we had this narrow, narrow envelope. In other words, we had a test that had very, very high specificity but very low sensitivity. You were missing a lot of people, but you didn't get any false positives, that's for sure. You didn't over pathologize when someone was autistic, they were really autistic. Today we have the opposite problem. We have a high sensitivity, low specificity test, sort of, I'm making that up, but you know, just to bring it to cancer diagnostics for people. So now anybody who's autistic should get diagnosed. But then we're stretching what that means. And a lot of the people getting diagnosed today, frankly, maybe without any support, would go on to do just fine. Do you worry that when the DSM 6 comes out, it could have a wider envelope and we could start to get to a point where someone might say, hey, are we over pathologizing this and are we getting to a point where, well, what does normal even mean anymore?

I agree with that so much so I actually ask that question all the time. I do wonder every time a child has a few of these traits whether or not we're coming up with the diagnosis. Every time someone is just a little bit different and rather than realizing there is neurodiversity, we're all different, we have to give a name to it all the time. It's an interesting debate and you will have you hear different perspectives. I mean the name gives us a way to get resources and help people. But I also concerned that we have to give everything a name. I actually wonder in the next DSM whether we'll end up taking a step back, whether the pendulum will swing a little bit.

And when is that due?

I don't know.

What was the gap between 3 and 4 and 4 and 5? 15 years?

I would say a couple decades.

It could literally be a decade.

It can be. But level one, we were talking about level one autism. So I'm concerned that the kids in level one autism might actually be part of several different diagnostic buckets. Children who identify with level one autism, they see one clinician, that person may diagnose autism, they see a second clinician, that person may diagnose ADHD anxiety, they don't even call it autism. I see this all the time in my clinic. I have kids who come to clinic and they may see three other clinicians before they saw me. Really Great clinicians, high standards experts. But there's a lot of blurry lines with the Level one autism, and you will hear different diagnoses. So back to your thoughts around future DSMs. I wonder how we're going to address level one autism, and is it the same condition? How many different conditions are in that bucket?

See, to me, the way I would think about that is I would hope that by the time we have to make that decision, we would have enough data and the data would ask the most important question, which is, how are we impacting outcomes? In other words, when we widened the diagnostic envelope and said that we're going to now have this ASD class one in here, that opened the door for more resources. That meant more kids had programs at school. What's a IEP?

IEP.

IEP. More kids have IEPs at school. What does that stand for?

Individual Education Plan.

Education Plan. And at the end of the day, what we want to know is, are those kids doing better? And if the answer is yes, then it's probably worth keeping. If the answer is that didn't make a darn bit of difference. All we did was create a bunch of anxiety for the parents, and maybe it didn't. Now, again, I don't know how one goes about answering that, but I would hope that somebody a lot smarter than me is thinking about it through that lens, because we can't lose sight of the whole purpose of this, like the purpose of a diagnosis anywhere in medicine should be to impact an outcome. A diagnosis for the sake of a diagnosis is not a particularly valuable tool unless you're an epidemiologist. But even there, it should be all in the spirit of how are we making people better?

I agree. And that's why, again, I agree, that the kids in Level one should be receiving services. Otherwise, what's the point of giving the diagnosis? Yeah, so they should be receiving services.

And if we need to call it something by a different name, who cares, as long as it gets the service that makes them better off than they would have been had they received no service? Before we get into more of the details about what you do, specifically, treatment wise, I want to finish one other bit of the diagnosis piece, which is can you talk a little bit about the overlap? You just did it sort of a second ago about asd, ADHD and anxiety. How often do they overlap? What do those Venn diagrams look like?

I'm gonna start off by saying we diagnose anxiety in kids, and there's that bucket, and there's many kids who just clearly fall in the anxiety bucket and meet criteria. And it's really clear to see that there are kids who have ADHD and clearly meet diagnostic criteria for ADHD and fall in that bucket. And then there are kids who clearly fall into the autism bucket. I'm going to focus on the autism bucket first. So we say that about half of kids with autism also have a diagnosis of adhd. If you look at the numbers, they're anywhere from. You can find reports for anywhere from like 40% to 70% of kids. But we say about half of kids with autism actually do have a diagnosis of autism. Interestingly, before the DSM 5, before 2013, we were not allowed to give both those diagnoses together, so they were mutually exclusive. If a child had autism, we did not give a diagnosis of ADHD. So starting in 2013, we did, and we give it a lot. So a lot of children with autism have ADHD symptoms as well, and we give that diagnosis. And about 40% of kids with autism also have anxiety. This makes sense when you think about the parts of the brain involved. When you think about adhd, we're thinking about executive functioning skills, we're thinking about prefrontal lobes. When you're thinking about anxiety, you're thinking about the amygdala. And then when people have done neuroimaging studies in kids with autism, we find there's many areas of the brain involved, but in particular frontal lobes, the amygdala, as well as the cerebellum, temporal lobes. There's many, many areas of the brain involved. But kids with autism do have challenges with executive functioning and anxiety, although those are not part of the diagnostic criteria. So those are associated symptoms, associated traits, associated diagnoses. So they're comorbidities, not part of the core diagnostic criteria. But there's a lot of overlap.

If 50% of them have ADHD and 40% of them also carry a diagnosis of anxiety, is there a percent of those that are overlapped and have all three?

Yeah, a lot of them have all three. I don't know the exact number for that one. Okay, this is the thing. These kids, they present with the core features of autism along with the executive functioning challenges and are anxious.

Okay, so now what can we say about kids with ADHD and anxiety? What's that overlap?

Kids who have ADHD anxiety, their numbers towards autism are not as high. So there are a lot more kids with ADHD who are not diagnosed with autism, but there's a lot of overlap between ADHD and anxiety. So ADHD frequently has a Partner is what I tell families. If you have adhd, you often have either anxiety or some other mood challenges or you have learning differences. So learning disabilities are frequently present to kids with adhd or you have oppositional behaviors. So there's often a second condition present in kids with adhd.

Say more about oppositional behavioral tendencies.

So there is a diagnosis out there called oppositional defiant disorder that is a diagnosis that I don't use quickly or often in young kids when I see oppositional behaviors. This is my personal approach, is that I will say I see a child with oppositional behaviors. What does that mean? Mean someone who argues, doesn't follow rules, disobeys lies. So kids with these types of behaviors. I want to understand the why before I jump into saying that they have oppositional defiant disorder. Technically, maybe they meet the criteria. Again, it's a checklist criteria for that name. But to me, that name doesn't help me. It's just a name. It's like, okay, I have a kid with odd, we call it. It's like, how does that help me? What do I do with that? So if I see a child with oppositional behaviors, I'm like, okay, what's the function behind that behavior? And so I can come up with reasons for why a child is oppositional. So we all have seen kids who have meltdowns, who fight, who yell, who argue. It's like, what's the function behind that? And so it may be that child is actually anxious. I'll tell you, a lot of oppositional behavior in kids is driven by feelings of anxiety and embarrassment. It may be the child is impulsive. That child lies and argues and yells no quickly because they're impulsive and they have untreated adhd. It could be that child struggles with understanding social context and social skills. They actually have trouble with their social reciprocity, but they're presenting with what looks like oppositional behavior. That child may be sensory overloaded and have challenges processing sensory information and therefore becomes overwhelmed and dysregulated and oppositional. The list goes on. The point is, is like, when I see a child with oppositional behavior and a family says, oh, well, someone told us it was odd. I'm like, now what I want to.

Come actually right back to that. I don't know what fraction of kids are getting that type of insight and attention, but my concern would be not enough. My concern would be that we're just in a world of ever expanding labels and codes and the so what is missing? When of course there isn't Really a field of medicine in which the. So what matters more? If you think about this person has hypertension, hyperlipidemia, insulin resistance. It's important to understand why. Yeah, but at a minimum, we have great treatments. If we don't know the why, if at the end of the day it's just deemed essential, hypertension, we have no clue why. Worst case scenario, we can put you on medication. You know, if weight loss isn't enough to reduce your blood pressure and fix your insulin resistance, at least we've got medications that work really well. But, you know, a lot of people would be. Would be hesitant to give their kids medication here. I want to talk, of course, about this in length, which is all the more reason why, boy, if you don't understand why this kid has oppositional defiant disorder. Because if it's like sensory overload, it's a totally different treatment path than if it's anxiety.

I agree. And so this is one of the challenging things about my field. And again, I'm going to come back to my boxes. I see a family, and I'm actually pretty transparent with the families I work with regarding that we don't know everything. I am really honest with them and transparent because they're like, doctor, what is the diagnosis? And the thing is, is families, they want to find a diagnosis because it helps. It's scary when you don't know what's happening. But I really walk them through that. There are these labels and diagnoses, but the risk is that they can see someone in my field and they do testing and you give a diagnosis. Like, I have kids, they come with a report. This child has odd. And I'm like, okay, well, what does that mean? What are we gonna do about it? And so the why is so, so very important. With, again, comes back to how do we create treatment plans? And it comes back to, again, like I said, you've met one child with odd. You've met one child with odd. And ODD, to me means, actually, I don't even know what to do with that. There's no treatment for odd. But, however, if I know if the child has impulsivity, I can treat that. If the child has social difficulties, okay, I know what kind of treatment plan to create there. If the child's anxious, I know what type of therapies to give. So it's really important to think about the why. It was actually one of the things when I left the traditional medical model and started my clinic, one of the things that I really noticed when I was making that transition and One of the things I wanted to remember when I started to work with families in my clinic was that it's not just about the diagnosis, the journey afterwards, and it's really about personalized care. And you can make such a big difference in child development, human well being by really understanding that specific child. And unfortunately, sometimes when you're on the treadmill in a medical model, it's really hard to have the time to really get to know a child. And I felt like I was. You have autism. Here's a list of 15 recommendations. Good luck. And you have ADHD. Here's a list of 15 recommendations. Good Luck. Without really getting to know the why behind that child's behavior.

Yeah. And I'm trying to think about how you compare this to adult psychiatry, right. Where psychologists and psychiatrists who really help people tend to focus less on their DSM 5. In this case diagnosis. They use that if there's a diagnosis there, we should know what it is. And it paints the contours of what we think about. But as my friend Paul Conti always talks about, he's like, if you don't know their story, you can't really help them. Now, that doesn't mean that knowing their story precludes using pharmacologic agents when appropriate. But what it means is you have to really understand the root. Is this a response to trauma? Is this a response to an underlying biologic condition? And again, I feel like based on the little bit I know here, adults seem to have more access to that kind of mental health care than children do. Is that a misperception on my part?

No, I agree, I agree. I don't think we've done enough in pediatrics in this area. But I agree, you have to know the story and understand the whole child. And so one thing about developmental behavioral pediatrics, which, by the way, is a very young specialty, you were the first.

Person at Stanford in that group. You created the group.

Yeah. So developmental behavioral pediatrics was only recognized as a subspecialty by the American Board of Pediatrics in 1999. So it's a very young specialty. But a key thing about this field is it's what we call a biopsychosocial specialty. And so what that means is we think about the biology, the genetics, the brain, the biology, the medication. We think about the biology. The psycho part is the mental health piece. So it's the idea of to support child development and behavior, you need to consider the physical well being as well as the mental well being. And then the social piece is the Fact that we don't live in isolation, we live in communities, we live in dynamics. And in order to help kids with their development and behavior. And what better way to promote human well being and health than to start early on and impact child development and behavior and self esteem and learning? The way to do it is you not only think about the biology, you think about the mental health and you think about the social, which is about family dynamics, parenting, school and education. This is key. This is the bridge between education and medical health, which honestly is hard to do in the traditional medical model, bridging to education, but it is really, really important. That's where our kids are learning and developing and growing and exposed to experiences. And so DBP looks at that whole picture. And I really believe that that is the way to support child development and behavior, whether there's a diagnosis or not.

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

Yeah, my husband got there in 04, I was there in 05. So I did my DPP training at the Hospital for Sick Children in Toronto. So I'm Canadian, trained at sick kids. An incredible place to train with volume of cases and complexity of cases. So it was a fantastic place.

Yeah. Probably one of the three largest children's hospitals in the world, right?

Yeah, it is, it is fantastic place to train. And so I did pediatrics, pediatric neurology and developmental behavioral pediatrics there. My interests and passions were always genetics, the human brain, developing human neuroplasticity. I did a lot of research in neuroplasticity and then 20 years ago moved to California in the Bay Area and took a job at Stanford. But the field of DPP was brand new. So as I said, like it is just starting out. So they did not have a developmental behavioral pediatrician yet at Stanford, so I was the first there. After me, they hired an incredible developmental pediatrician by the name of Heidi Feldman, who then created the division of DBP at Stanford. And she's still there. And they have a fantastic group there now. But I arrived, there was nobody else. I was at Stanford for a number of years and did research, clinical work, as well as medical education, teaching. And then after that I focused on the clinical piece and went to a large clinical organization, did clinical work. But then 10 years ago, in 2014, decided to leave the traditional model and start my own multidisciplinary clinic.

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

I felt that I could help my families and patients more and or differently. I wanted to make an impact. That's one of my passions, is always to make a difference. And I felt that I was a little bit stuck in the model. And it's just the medical model, there's so many good things about it. But to help the families the way I wanted to with my values, which I can describe, I needed to leave. And what did I value? So, one, I believe in promoting health and well being. And that's all about dbp, development of behavior, it's about promoting health. Where medical centers are, have been in the past primarily focused on treating disease. So that was one thing. Two, I really believe in multidisciplinary teams and really having an integrated team in this area. As I described, understanding the whole child requires not just a physician, requires therapists, psychologists, teachers, different types of professionals. And I really believe that to make a difference, those professionals have to be integrated. If you want a touchdown, all the players need to be reading the same playbook. And so I felt like a lot of the families I was seeing, they would come see me in the medical center, the doctor. But there was the school and there was the therapists and we had all these different silos. So I really believed I needed to bring the silos together. Another thing is I believe in community collaboration. So that's actually the bridge to education and that's actually really hard to do in a standard medical model is to really have collaboration with the school. So now I do school observations, I go to IEP meetings, I work with teachers in classrooms because I know that to move the needle with the patients I see, I need to do that.

You need to see what the kid's doing at school.

I need to see what they look like at school. And then I believe that the family is the patient, not just the child. If I am going to make a difference in a child's life, I work with the parents a lot. It's amazing how powerful parenting can be and training parents. And again, this is the social piece, the dynamics. Understanding the whole family situation is really important to make a difference in a child. And then lastly, I believe I love learning and being innovative and thinking outside the box. And so I decided to set something up where I can continue to like ask questions and challenge the system and try to make it better.

So tell me about your team. You said you have 25 people on the team.

So we have a few different programs. We have a behavioral team where we focus mostly on kids with autism. However, probably about 20% of the kids who work with our behavioral team, don't have a diagnosis of autism, but do benefit from behavioral therapy, social skill groups, parent training that focuses on behavioral models. We have a mental health therapy team that supports kids and teenagers with anxiety, depression. So we offer different types of therapy for that. Mood dysregulation, adhd. We have psychologists who do testing for diagnostic assessment and then we have a medical team. But it's not just giving medicines. I do prescribe medicines. But again, it's like that is a portion of what I do. I look at the whole child and it's really understanding the therapies, the parenting, the school piece, and medication when it's important and can help.

So there's something called aba. Remind me what it stands for.

Applied Behavioral Analysis.

Okay. It seems to be a somewhat polarizing topic in the field of autism therapy. Maybe describe what ABA is and explain perhaps why it's so polarizing.

Yeah. So ABA means a million things these days. And it just like autism means so much as well. So ABA is a behavioral intervention that traditionally has been used with kids with autism. It is about taking a skill and breaking it down into smaller sets, smaller subsets. Traditionally it was very direct, adult directed, repetitive, working on a small skill. All these small skills add up to a bigger skill.

What's an example?

So an example would be, oh, you put me on the spot and I gotta think of an example now that's really good. Okay, let's think of something. It might be something to do with greeting someone. Okay. Appropriate greeting. And appropriate greeting would be integrating verbal as well as eye contact, as well as maybe turning your body towards the person. So when you greet them, when you meet a new person. And so for someone with significant autism, that's difficult. And they need to learn how to turn their body and make the eye contact and do the vocalization and how to integrate that. So for that skill, you'd work on the different subsets. And so you might be first working on, if you want to greet someone and acknowledge them, you're first going to look at them and have that joint attention. So you're going to teach a child how to make eye contact. Initially, we did ABA with something called discrete trial. That's why it's controversial. Discrete trial, which is still used today and still can be very helpful when it's combined with more naturalistic forms of aba. Discrete trial would be about teaching a child to make eye contact and they get a reinforcer every time. So make eye contact, get a reinforcer, positive reinforcer. So it's positive reinforcers. It is a lot of repetition, practicing, teaching a child a new skill. And then you would add the other layers to it. The eye contact and then the greeting and the vocalization, turn your body. You would add all that together to come up with this larger thing of how do you approach someone? So discrete trial has been around for decades. That's the part that's controversial because people say, oh, this is very repetitive, and it's not based on relationships. So over the years, there have been more naturalistic ABA methods created naturalistic in that it occurs more in a child's natural environment. It is not just at a structured table where you and I are practicing eye contact, natural environment, also trying to understand the child's natural motivators. So, for example, it might happen at a park, and it might happen. We know that child loves to be on the swing. So rather than sitting at a table and me saying, like, make eye contact, here's your reinforcer. Make eye contact, here's your reinforcer. Now we're at a park. This child wants to be pushed on the swing. Well, we're going to help this child learn that if you want me to push you on the swing, you got to look at me and somehow acknowledge me. So I go push you. Otherwise, I don't know that you want to be pushed on the swing. And so those are more naturalistic forms. One of the most naturalistic forms is something called pivotal response treatment prt, which is actually training the parents in these skills, because that's really what it's about. It's not about whether this child can make eye contact with therapist A at the table. It's about how does this child understand how to use eye contact when it's appropriate to use it, and the power of it in natural settings. And so when you train the parents how to do it, then they can practice at the park, at the coffee shop, on the playground, the parents. So that is the most naturalistic form, teaching the parents. This comes back to parents how powerful it is if you teach parents. But parents work with the child in a natural setting with natural motivators.

Are there limitations to treatment in families with single parents?

Yes. When you said that, I'm thinking like, it's just a single parent. It's time and resources and driving to therapies. Again, it depends on how significantly impaired your child is and how many therapies they need.

Yeah. And I'm just trying to understand what the socioeconomic toll is. So I guess think about that in multiple ways. So what is the typical cost of therapy? So how much of this cost is covered by insurance typically? How much of this cost is embedded within the school program? So obviously I think an IEP is included if a kid's in public schools, correct? Yeah, if they qualify for IEPs.

Yeah.

But is ABA therapy or PRT or any of these things, are they covered by insurance companies for kids?

They can be. It depends on the state. So how it's covered is different in different states. I'm from California, so in California, ABA is covered if you have a diagnosis of autism. That's where the diagnostic piece is important. So then it is covered.

And what about the impact of other siblings? So is there anything that you've noticed about the nuances around if a kid has an ASD diagnosis and they have other siblings that don't have diagnoses or they do and where they are in birth order and just trying to understand the overall family environment and how it pertains to treatment.

Yeah, there's actually so many things you can say about that. So I'll first start by saying that siblings of children with autism are themselves at risk for either autism or autism like traits or something called the broader autism phenotype. They may actually not have autism, but they may have a few traits of it and or at risk for other developmental disabilities. So kids who are siblings also at risk for language delays, anxiety. So already they have again that predisposition, that load to have some developmental differences. So that's one.

And how much of that is based on the fact that this is a largely genetic condition and if they're siblings, they share genetic traits even if they don't have all of them. And how much of that is the siblings develop those in response to anything from mimicking the sibling with autism to responding in frustration to the behaviors of the kid with autism.

There is a big genetic piece to this. So they truly do have these conditions, language delay, autism traits, adhd. It's very often you see a sibling with one of those other conditions and there's that genetic piece. But you're right, there's a behavioral component, coping component, anxiety component, that may be be related to family stress, attention seeking behavior. At the same time, I also see the opposite. I also see many siblings who have incredible empathy for people who are different because they have a sibling who has a developmental disability.

Okay, so going back to aba, from hearing you right, I'm not hearing you say it's good or bad. I'm hearing you say it's just another tool in my tool bag. And it has elements of it that are valuable if applied probably in the environment of the child.

So I do recommend it. It should be a part of a child's treatment plan. The tricky part is you want it done with people who are well trained, who understand autism, who understand behavioral therapy. Well, that's the. Why it's sometimes controversial is because there is such a huge demand for therapy for kids with autism, because the numbers are so high, it's hard to find enough people to provide therapy. It's also. It's an industry, and there's people who take jobs in this industry who actually are not well trained or well supervised or really understand the nuances. Because if you know one child with autism, you know one child with autism. And if you're just following a recipe, you might run into people, therapists, who are not making a huge difference and are not that helpful. But I do offer it. I do recommend it.

What is the current size of the autism treatment industry and how does it compare to what it looked like 20 years ago? In other words, has it grown commensurate with the increase in the prevalence, or is there a greater burden on the per capita therapist today?

There's a burden. I don't know the exact numbers, but it's grown. But because it's growing, it's scaling. And when you scale, you dilute. Yeah. You run into issues with quality when you scale. So it's hard. But that's the thing. How do we keep up?

So what do you say to a parent who's listening to us, who's trying to navigate this for their child? And they don't live in the Bay Area, so they don't get to come and see you. What questions are they asking? What are they trying to do to find the best care for their kids, regardless of where they lie on these spectrums of anxiety, adhd, or the various levels of asd.

So what my advice would be for them would be start with your pediatrician. You start with your pediatrician. But you need to find. Your hope is with the pediatrician that they are able to connect you to resources and the network. Because you really need to find a team. It's finding a team.

How likely is that?

It's hard.

Yeah. If you don't. If you don't live in Boston or San Francisco or the major cities, I'm guessing that this multidisciplinary approach does not exist.

No, it's not easy to find.

So what are the options then? What's the next best thing?

Yeah, you try to create your team. But the thing is, I talk to families all the time. This is so stressful for a parent who's in a situation like this because they don't know anything about this. They could be highly educated. And then we're talking about families who actually, if you speak a different language and don't have higher education, this is a disaster. But even for families who are well educated, trying to understand and quarterback this, basically you need a quarterback to help you decide, is this ABA helpful or not? Should I be focused on speech and language therapy or ABA therapy right now? What should I be advocating for at my IEP meetings? You really need someone to help you with that roadmap. So we need to help families more with that. I think of myself as a Sherpa sometimes, guiding people along this journey. And it's the roadmap. Every year we pivot and turn. Where should we spend more time? Is it in social skill groups? Is it speech therapy? What should we be asking for? And so your question is like, yeah, this is hard to find. And so if you can't find it, you're looking for somebody who may not be a doctor. It might end up being a really good ABA therapist or a psychologist in your community who can help connect you. There are state programs.

What is a parent asking when they meet a provider to figure out, is this going to be a good fit? I mean, obviously one option is just ask nothing and wait and see how it pans out. And in six months, ask yourself the question, hey, is my kid doing better today than they were six months ago? But if you as a parent had the chance to meet several providers, so the, hey, look, I happen to be lucky. I live in a city. There's three ABA providers here. I'm going to go and interact with each of them. What could I as a parent do to understand where should I go first? Which of these three should I pick? What are the clues that tell me this person is going to have a higher probability of success?

So one thing is that you make sure that they have the philosophy, one size does not fit all. So that is key, is that this person needs to understand personalized care and that they don't just give the same treatment recommendation, same thing to every single child. It's not black and white. So you need to make sure that that provider is flexible in their thinking and their treatment approach so that they can provide individualized cares. One, two would be that they would be proactive in helping you create some sort of team. So it may not be a team like I have under one roof, but they are open to the idea of collaboration meetings with the child's speech therapist or teacher. So someone who is open to it, but will also be proactive in arranging collaboration meetings, maybe once a season. Three would be, I think, someone who has skills in. I mentioned the parent training piece. I think that's a really important piece. It's not just parent education. It actually is parent training, because I've seen that really make a difference.

I think that's a great list. I'm thinking about this through the lens of how do you scale what you're doing? And there's two ways to do it. One is you just keep replicating a model that looks just like yours. So really big multidisciplinary model, but that can only be supported in a certain geography. I mean, to have a team the size of yours, you're not going to be able to put that in every town. And yet I think it seems unlikely that this is a condition that discriminates by geography. And therefore there's got to be Half the kids in this country that have any of these conditions are going to be in areas where they're never going to have large turnkey multidisciplinary offerings at their disposal. So their parents are going to have to do sort of the heavy lifting. And unlike cancer. So if a child gets cancer, a parent and family can go to another city for treatment. If you happen to live in Austin, Texas, when your kid gets a certain type of cancer, but Boston Children's Hospital, or pick your favorite city that has the greatest center for that. It's not an unreasonable thing to potentially go there for treatment. But this is not something you're going to go and do in another city. This has to be an integration into your life where you are.

Yeah, this is the journey. This isn't a quick thing. This is years. This is a journey. And the whole point is to have it integrated and generalized in the child's life. We were just talking how ABA in some structured clinic. That's not our goal. The goal is to have a child showing us these skills in real life, in their real life, in their classroom.

What percentage of the children that present to your clinic with a diagnosis of adhd, plus or minus anxiety, require pharmacotherapy in your clinic and your experience.

Before I answer that, I'm just gonna emphasize. So kids who come to my clinic with ADHD often come to me. Not always, but often come to me because it was a little bit more.

Complicated than just there's a selection bias into your clinic. If this were straightforward, they Wouldn't be coming to you.

Yes. If it was straightforward. Hopefully their pediatrician can manage it.

Okay. Yeah, makes sense.

Yeah. But still, the percent of kids who are treated with medication depends on the age of the child and the severity of the adhd. So younger kids in my clinic, I will use behavioral interventions.

First, define young. What does that cut off for you?

So I see preschoolers who come to me because they've been asked to leave multiple preschools because they are hyperactive. And in that preschool years, although you could technically make the diagnosis, I share with the family that we're probably going down this path, whatever we're going to call this in the next couple years, let's start working towards helping your child build skills to regulate, manage their hyperactivity, manage their impulsivity. So we start with first line treatment for ADHD in kids under six is behavioral parent training. So that's first. So under six, it's behavioral parent training. We do that first and try to get that to help. We may or may not need to add a medication. The guideline for 6 and older, first line treatment is medication plus behavioral parent training. And so medication makes a big difference. Medication can be very, very helpful. And I read the family where they are at on this journey and their family values and how they're processing the information, and I listen to their questions and concerns, and I build trust. And so some families are ready to start medication right away. Other families have questions. I work at developing a relationship with that family, answering their questions. And most often, we do move towards medication because we know it helps. Most of them say, I wish I started sooner.

I want to dwell on this point, Trana, because I have to believe there are a lot of people listening to us. Maybe not so much because I don't think my audience is quite where I'm going. But there are going to be people who understandably come at this and are really judgmental, and their narrative is going to be the these goddamn preschools trying to tell me a kid has adhd. Maybe it's because the preschool's just overcrowded and the people who work at the preschool are too lazy to actually let these kids play. Let kids be kids. There's nothing wrong with a kid that's hyperactive. You just got to give him more to do. Blah, blah, blah, blah, blah, blah. This is sacrilege that we would ever give a child medication just because they're hyperactive. So that's a narrative.

Yeah, for sure.

Now, again, I don't think a lot of people, if they're sophisticated, subscribe to that. Because I think a person who's sophisticated would hopefully not make a judgment like that without understanding the fact base a little bit more. Would you agree that the best argument against that logic, which is not an argument that says every kid should be on medication, it's an argument that says you have to weigh the pros and the cons of being unmedicated and what the impact on your education is going to be and the long term success you're going to have as an adult, as a well adjusted adult, versus the accepted risks of any medication and the potential upside it has towards allowing that child to learn. Because again, I always like this framework you have which is you bring it back to what is the adaptation of the condition, what is the adaptation of the phenotype, if it is disruptive, if this is a difference in a child's education, if this is the difference between a kid going to college and not. If we believe that matters anymore, or being successful in their career or not, or having pro social relationships versus not, then maybe we accept the risks of medication. So maybe you can articulate that more eloquently if you have a different view. But that's kind of how I like to think about things that seem at the surface absurd.

I love all those points you brought up because it is a risk benefit ratio that you have to consider. You have to consider there's risks in everything we do, there's risks in all medications, there's risks in everything. So you have to consider both risks and benefits. When I'm working with a family, I talk to them about the research and we actually have a lot of research around safety and long term outcome and the outcome of individuals with ADHD who are left untreated. But actually, more importantly, I get to know their child though see this thing as I get to know them, I share with them the research, the safety research, all sorts of information about the medication, but what's really important. So this is the idea about me going and watching the child in class, me talking to the teachers, getting to know that family more really understanding, they come to see me for a reason. If things were great, they wouldn't come to see me, they've come to see me for a reason. And even though the school maybe initially was the school who said, you little guy is way too busy and you need to see a doctor about this. But when I get to know the family, I find out, well, actually dinner is really stressful and bedtime routine's really stressful. Everyone, everyone's in Tears in the morning. And so I get to know them and it's actually that personal part that helps them understand their child. And I come back to self esteem and interpersonal.

Your kid is not a statistic to you.

Yes, that's exactly it. Sometimes we don't use medication. I am the first to say, if your child doesn't need it, we're not going to use it. Although we know that medication can make a really big difference.

I've discussed this on some previous podcasts. So is Vyvanse still used? Is Ritalin still used? Is Focalin used? I mean, what's in your toolkit in that world?

ADHD medicines. We're talking stimulants and non stimulants. First line treatment considered is stimulants. Within stimulants, we have two different medications. We have one called methylphenidate and one called amphetamine. Methylphenidate. We have many brands. That's the Ritalin, which has been around since, I believe the 1950s. We've got Ritalin, we've got Focalin, we've got Concerta. We have lots of different methylphenidates.

What was the other one after Focalin?

Concerta. And there's many more brands. They're all different brands.

And how do they differ? Are they differing in pharmacokinetics and half life? What separates those three drugs?

For example, how the medication's released?

Okay, so it's just a timing of.

Release and pharmacokinetics, timing of release and the mechanism of release.

But it's literally the same molecule.

Yeah, it's the same active ingredient, methylphenidate. But it's interesting, kids respond differently to the different medications, the brands, because the release mechanisms are different. So some kids are sensitive.

So in other words, if a kid comes in and you try one of these and you don't get the response you want, you don't necessarily abort the entire molecule. You might switch to a different formulation. And I only say this because I can't tell you the number of parents I have spoken with who have said my kid was on Ritalin. It was a disaster. When they switched to Focalin, it got so much better.

Yeah, that's exactly right. And there's no science, unfortunately, to tell us which one's going, which one's gonna work for your child. So you have to basically try a few.

Okay. And then the other one you said was just straight amphetamine.

Amphetamine. So that's Adderall, which has been around since the 1930s. And then there's. You mentioned Vyvanse, Vyvanse, Dexedrine. So there's medications in that group and again, same deal.

The difference between Vyvanse and Adderall is release and kinetics.

Yes. Vyvanse is actually called a prodrug. It's actually just got a little molecule attached to it that needs to be cleaved in order for it to work. But they're all, yeah, the same.

Again, it's very counterintuitive to people. Why you take a hyperactive kid and give them a stimulant. Do you want to just give the brief overview of why that works?

So the way these medications work is they increase dopamine and norepinephrine in the synapses between the brain cells in the parts of our brain that are important for executive functioning, attention, inhibiting impulses. So the part of the brain, the prefrontal lobes, where that all the executive functioning attention happens. Our brain cells have to communicate in order to see that behavior attention. These medications, although they're called stimulants, what they do is, is they. They increase the levels of dopamine and norepinephrine in these synapses, the gap between the neurons, and they improve the electrical activity and communication between brain cells.

What are the most common side effects you caution parents about with these drugs?

So the side effects can be annoying, but they're not life threatening. The most common one is decreased appetite at lunchtime if you're taking a medication that lasts the whole day. So there's medications that last three or four hours, which we used to use a lot a couple decades ago when I first started doing this. But about 20 years ago, we started using extended release a lot more. And so extended release is that it lasts 8 hours or 10 hours for the day or 12 hours a day. And so those medications impact your appetite at lunch. Breakfast and dinner are usually fine. There's this chance that it impacts sleep onset, which is really important because sleep is super important, kids. But it can impact sleep onset. And if that's a problem, we adjust the timing of the medication in the morning.

But these are generally single administration, first thing in the morning drugs, I assume.

Yeah, they're really easy to use because you take it in the morning, they start to work, the extended release will start to work within an hour, and then they're working for the majority of the day. Then they come out of your system at the end of the day. And so tomorrow, unless you give the medication to your child again, it's like.

They'Ve never been on it.

It's like they've never been on it.

What are the differences then, between the Ritalin class and the Adderall class? Do you have any suspicion one way or the other as to which is going to be more effective if you were to prescribe Focalin versus Vyvanse?

Yeah. So when I first meet a young child, I generally start with methylphenidate. And that's what most clinicians do with little kids. And the reason for that is that the meta analyses show that kids tolerate methylphenidate a tiny bit better than amphetamine, although amphetamine is a little bit more bang for your buck when you're treating the symptoms. That being said, no kid is a statistic. Every kid's different. So I have just as many kids on Adderall as I have on Ritalin.

Interesting.

Yeah. So I use every single brand out there, but I start with methylphenidate because it's shown to be tolerated better.

You mentioned a second ago that if your kid's been on this drug every day for a year and experienced all these benefits and then they come off the drug, it's like they were never on the drug. Does that suggest that in the. I hate to use the description this way, but I think you understand in the drugged state, you don't get to do behavioral therapies that also have a positive impact independent of the drug, such that if the drug comes off, the phenotype is changing. Is that not to be expected?

I want kids to be actually practicing skills when they're on the medication.

Yeah. In theory, they should be able to do a better job. It should be easier for them to practice the skills on the medication.

Yes. So let me say a couple things. So in theory, when they're on the medication, it's easier for them to practice paying attention, controlling your impulses, controlling your hyperactivity. In addition to that, this is where the behavioral parent training part comes in, which is actually now a recommendation that every family should have.

Should be doing training specifically for family, not just child.

Yes. Amazing how powerful parents can be in modifying the behavior of their child. So parents undergo the training and the child might undergo some sort of therapy regulation group. When they're older, they undergo executive functioning coaching to learn organization and planning. So what it is, is you are trying to develop these skills. So when we practice something over and over and over again, not only we develop new behavioral strategies, behavioral patterns, new habits, we actually positively impact the developing brain. That's neuroplasticity. Which is one of my passions, is neuroplastic. But we impact the brain through experience and our behaviors. So when a child has adhd, it is a wonderful time to practice new skills and you actually impact neural networks.

So does that mean that you're telling parents, or at least holding out a hope that, hey, your kid is 7 or 8 years old, we're going to put them on Ritalin. This might not be a lifetime thing. Do you give them that hope or do you not commit to anything one way or the other?

I don't commit.

I get asked that question all the time for the types of medications I put patients on. If I put patients on a lipid lowering medication, generally their first question once you get through the why should I be on this and what are the side effects, et cetera, is, am I going to be on this for life?

Yeah. So what I tell families I have no crystal ball, I can't commit. But I do have many, many patients who do eventually come off medication. Some of them maybe they shouldn't have come off medication. They actually should stay on their medication. But I have many patients who come off and do really well.

Is it naive to think that because ADHD primarily impacts the prefrontal cortex, that you would see at least a subset of people when they reach their late teens as girls and mid-20s as boys, when they reach maturation of that part of the brain, that at least a subset of them should be able to develop potentially the skills to overcome the genetic component of this? Or is that not necessarily correlated?

No. I see a lot of kids who do find strategies to compensate and who do no longer need their medication as teenagers or young adults. I have a lot of kids who are like that. But I think it's really important that they start early developing strategies and new behaviors. I think that is really important in strengthening those neural networks.

So what about the non stimulant class of drugs here?

There are non stimulants that we use. One is called Strattera, which also acts on norepinephrine and increasing the norepinephrine levels in the synapses. And then there is a couple of old blood pressure medications we use. One's called guafacine, the other one's clonidine. Those are alpha 2 agonists. So they act in a different way with closing channels in the post synaptic neuron. So it's a different mechanism. But all of those medications also help with the communication between neurons in the attention center in the brain. The difference is the non stimulants have to be taken every day, unlike the stimulants, in order for them to work. So meaning they're taken every day and you need a steady state in your body.

Yeah. Do you ever mix these two or is it one or the other?

Oh, you mix them. Often you do. And so often they do not have the side effects with the poor appetite. And sometimes they can be really good with kids who have some emotional dysregulation, impulsive emotions. So we'll often use them with a child who has a little bit of that irritability, emotional dysregulation. And sometimes we're using both the stimulant and the non stimulant at the same time.

Are there any medications that typically show up in kids with autism but without adhd? So let's just say kids with autism plus or minus anxiety. What is the role of pharmacotherapy?

There's no medication that treats the core symptoms of autism. The core symptoms don't require medication, it's therapy. We use medication in kids with autism to treat target behaviors and symptoms. So we use medication for the symptoms, no matter the label. So whether or not the child with autism has ADHD or not, we still may use an ADHD medicine. If they're hyperactive or impulsive, we still may use it whether or not the label's there.

Got it. So you don't need the diagnosis to decide. In other words, there are kids with autism that are going to be on medications and it's really just a function of the symptom.

Correct. So the target symptoms we usually treat it is the attention, hyperactivity, impulsivity, where we'll be using the stimulants, or the challenges with emotional regulation. Where we'll use a non stimulant, we may use an anxiety medicine. So a selective serotonin reuptake inhibitor, SSRIs such as Prozac or Zoloft, we may use that for anxious feelings. We also use that sometimes for rigidity. So kids with autism who struggle with rigidity and transitions, it's often anxiety related. So we'll use the SSRIs there. And then kids who have really aggressive behaviors and may injure themselves, then we are talking about atypical antipsychotics. I'll just share with you. I don't use a lot of those myself at that point, if the child is having those difficulties. I often working with a psychiatrist, again.

I think it's just got to be so hard for parents to potentially stomach putting children on psychiatric medication. But what you said earlier is sort of interesting, right? Which is most of them are coming back after saying, I wish we did this sooner. Which I suppose would be the most affirming thing you could ever hear in that situation. What are the things that they typically notice when they come back to you and say that? And how long does it typically take?

Well, with the stimulants, it could be pretty quick. They're like, we're glad we did this, and this is making a big difference. The impact of stimulants is right away, you see the benefits right away.

What do the kids say? Let's assume a child is old enough. So let's assume you're working with a 7 year old or a 12 year old who can articulate their feelings. What do they come back and say to you?

They share with me that it helps them with their focus. They feel more successful at school, and they share side effects.

What other side effects do they complain of besides appetite suppression?

So I will sometimes have high school students who tell me that they feel less social and funny when they're taking their ADHD medicine. So they're a little less impulsive or spontaneous. And so we talk about that, and I listen because it doesn't have to be black and white. All or nothing. Our goal isn't to make someone 100% focused 100% of the time. It's like, okay, so we want to improve focus. None of us are focused completely all the time. So when I have people come to me with side effects, I'm like, okay, well, probably the dose is wrong, or maybe we should change to a different medication. This one particular medication may not be the right match for you, so we should need to change it and find one with less side effects. So I think that the key thing is having a relationship between the doctor and the patient. Lots of communication, and the idea that if the patient is experiencing side effects, that they tell somebody. So that you can adjust. You change the dose, you change the timing, you change the brand. It's just weighing pros and cons.

You hear this phrase from time to time, which is that kids with autism have superpowers. We might think of an example like, okay, well, Dustin Hoffman's character in Rain Man, I mean, obviously highly, highly impaired for most of life, but clearly had a superpower. He could count cards and toothpicks. Obviously that's kind of the Hollywood version of that. But is there truth to this idea that kids with autism have superpowers? Or is this something that you would put more Brackets around and say, well, sometimes those kids who are in Class 3, where they're really impaired, maybe there's something there. But it's a lot harder to see than the kids in class one, for example.

It is. So there is a difference. Class three versus class one, for sure. It's harder to see. It's harder to see in Class 3, Class 1. A lot of superpowers. Memory could be one of them. Attention to detail, really good with remembering rules and following routines or a set order of operations. There's a lot of strengths with the kids in class one.

There are a lot of famous people I won't name who have even talked about themselves as having mild forms of autism, Asperger's. So you would almost think that it's predisposing them to some of their greatness in the fields that they're in, often very technical fields. Is that consistent with what you see in the children? Yes, it is more of a predisposition towards engineering, technical fields, STEM in general.

Yeah, definitely with that profile, like I said, I called it a learning profile, a thinking profile. And so things where you need a little bit more inferring, there's abstract inferring or the social piece. It may not be their strength, but where you need to dive deep into some details, persevere, stick with something hyper, focus on that, you do really well. And so a lot of people, once they find their passion as a young adult, if they find a career where they can actually dive in, they can dive deep and do really, really well.

What do you think is kind of the most important thing you want people to understand about anxiety, autism, adhd, that you think is either misunderstood or not understood at all?

I think that there's a lot of overlap. I think people sometimes get stuck on the label and name. And although there's so many positive things, we're talking about the diagnosis, you need to get resources. I think I get concerned that people get stuck on a name and don't actually see the person beneath that name. I think that's my key thing. I've had so many experiences where families are like, but they told me it's autism, it has to be autism. If you think otherwise, what's wrong with the system? And this is hard because in this field, there's a lot of gray. And so I think that's what it's about. There's gray. It's a moving target. We've changed the names and the definitions multiple times in the last couple decades. They probably are going to change again. So it's for us to be flexible with our thinking that the definitions may change again. But there are these learning styles. And so if you've met one person with one of these names, you've met one person and it's really important to understand that person in order to help them with leveraging their strengths and then understanding what kinds of gaps you want to fill and what kinds of skills you want to work on.

Trana this has been really, really fascinating. I guess my only frustration in this discussion is the concern that there aren't enough people like you and your colleagues out there to match what is very likely the psychological burden of these conditions across kids today. And I'm only speaking to the United States. So I think if you were to think about this globally, I won't attempt to make a statement because I simply don't understand what the prevalence is or what the resources are. But I think we could probably say in the United States that there are far more children and families that are impacted by the AAA than there are multidisciplinary teams that can take care of them. Are you optimistic that 10 years from now this model is going to be different? There are going to be more people that are going to want to come to practice this in the way. Where is the long pole in the tent? Is it getting more people to simply go into these fields? Is it a better payer reimbursement structure to incentivize more people around a multidisciplinary approach? What is it going to take in 10 years to close the gap between demand and supply?

I think it's both those things you mentioned. It is definitely training more people and trying to think about how to use and recruit people who are also going to support, for example, the developmental behavioral pediatrician or the psychiatrist or the psychologists, for example. We need more DBPs, but we also need then like more nurse practitioners or other allied professionals who can support the team. So it's being creative and innovative with how you create the teams and find enough people to be in the on these teams. But then how it's reimbursed and making sure there's access to these teams will be really important. I really believe in the bridge to education as well, which is not something that is part of an insurance.

Well, I would say that I was literally just about to ask you the following question which dovetails into that, which is are we thinking about this the wrong way? Are we thinking about this as something that should be done through health care when maybe this should be done through education? If you had unlimited budget one way or the other, this has got to get paid for. So it's either going to get paid through health insurance or it's going to get paid through systems in education. Do you think that the burden is disproportionately on the healthcare system today and it should be a shared burden with the education system? And I'm not saying that to be critical of the education system they would need the funding and the resources to do this, but is that part of the issue is that you're always going to see these things manifested in the education system and that's where you're going to get the most bang for your buck when you address them.

I'm going to go back to the bridge because it is. It's like the insurance. They'll say that parts of this intervention are educational, so they're not responsible for it. And then the educational people will say that this part is this medical thing. It's actually not interfering with the classroom, but you need to realize to help that child move the needle, you have to have both systems working and talking together and collaborating together if you really want to move forward. And so it's a totally different system, but I really believe in bridging education, mental health and medical if you want to make an impact on child well being and health.

I'm really hopeful that this message spreads and that we see more and more of this type of integrative approach because it really makes sense. So thank you so much for your time and appreciate you coming out here.

Thank you.

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