Peter Attia MD330 – Autism, ADHD, and Anxiety: the rise in autism & an approach to diagnosing & treating children
CHAPTERS
- 0:00 – 3:03
Why the "why" matters and Trenna Sutcliffe's background
Trenna Sutcliffe stresses that care should go beyond a diagnosis to understanding the specific child. Peter Attia welcomes her and asks about her training in genetics, pediatrics, neurology and developmental-behavioral pediatrics, then introduces autism, ADHD and anxiety as the topics.
- •Care is about the journey after the diagnosis and personalized understanding of each child
- •A traditional medical model can reduce a visit to a list of recommendations
- •Sutcliffe trained in genetics, pediatrics, pediatric neurology and a developmental-behavioral pediatrics fellowship
- •Her clinic sees patients up to age 18
- 3:03 – 11:19
How anxiety, ADHD and autism are diagnosed and at what age
Sutcliffe explains that all three are clinical diagnoses with no biomarkers, based on trait checklists, multi-setting data and impairment. She gives the youngest ages at which each can be diagnosed and describes the different types of anxiety.
- •No blood tests or brain scans exist for these conditions; diagnostic labels are man-made boxes
- •Impairment in a child's "job" of learning, friendships and community is a key criterion
- •Autism can be diagnosed at 18 months, ADHD as young as four, though she waits closer to school age
- •Anxiety types include generalized anxiety, phobias, separation anxiety, selective mutism and OCD
- 11:19 – 17:01
Assessing impairment and self-esteem in ADHD
Attia asks how a parent can tell whether an energetic child's traits are a problem. Sutcliffe describes the bell curve, the central role of self-esteem and peer relationships, and the techniques she uses, such as talking about a third person with younger children.
- •These conditions sit on a bell curve, and she prefers "learning differences" over "disorder"
- •Self-esteem, peer relationships and access to learning are key impairment questions
- •Younger children often reveal feelings more easily when discussing another child
- •Children typically reflect on themselves only when older
- 17:01 – 28:33
How autism is diagnosed and how the diagnosis evolved
Sutcliffe describes the two diagnostic domains for autism, the three social communication areas, who performs the assessment, and why a label alone says little about a child. She also covers how the 2013 DSM-5 folded Asperger syndrome and PDD-NOS into one spectrum.
- •Social communication differences are needed in all three areas: reciprocity, non-verbal communication and relationships
- •Restricted interests or repetitive behaviors are the second domain
- •Developmental-behavioral pediatricians, psychiatrists or psychologists usually assess; milder cases need multiple visits
- •The 2013 DSM-5 merged Asperger syndrome, PDD-NOS and autistic disorder, with specifiers for intellectual disability and language impairment
- 28:33 – 32:51
The rise in autism prevalence: genetics and environment
Attia cites CDC prevalence figures and asks what is driving the increase. Sutcliffe says definitional changes don't fully explain it, describes autism as multi-hit and highly heritable but polygenic, and lists environmental factors implicated.
- •Prevalence has risen from roughly 1 in 150–200 to 1 in 36 in the CDC figures Attia cites
- •Sutcliffe says people in the field believe definition changes don't explain the whole rise
- •Heritability is cited as 70 to 98 percent and involves hundreds of genes, different in each child
- •Factors such as pollution, maternal infection, stress, diet and parental age have been implicated, none alone
- 32:51 – 50:33
Epigenetics, causality, and whether severe autism has risen
The conversation explains epigenetic methylation and the unproven idea that exposures could be passed across generations. Attia voices concern about an epidemic without a clear cause, and they discuss how little data exist on the severe end of the spectrum.
- •Epigenetic changes alter gene expression without changing the DNA sequence
- •Multigenerational transmission is described as controversial and not established
- •Attia worries about acting on an epidemic without understanding causality
- •Few studies break out levels 1–3, and clinicians are inconsistent in assigning them
- 50:33 – 1:00:16
Level 1 autism, missed support, and adults who see themselves
Sutcliffe explains how classification changes affected access to services and why children with level 1 autism often go without support despite responding well to coaching. They also discuss how adults with similar traits found their paths and how parents recognize themselves in their children.
- •Before 2013, children with Asperger syndrome or PDD-NOS often lacked covered support
- •Level 1 children are often unsupported because of their strengths, yet respond well to coaching
- •Many adults with similar traits likely built happy, successful lives and relationships
- •Parents often recognize themselves, and that validation can be empowering
- 1:00:16 – 1:05:50
Over-pathologizing, shifting DSM boundaries, and outcomes as the goal
Attia asks whether a widened diagnostic net risks over-pathologizing. Sutcliffe shares that concern and the blurry lines around level 1 autism. Both agree a diagnosis should be judged by whether it improves outcomes and services.
- •Attia frames wider criteria as higher sensitivity and lower specificity
- •Sutcliffe wonders whether the pendulum will swing back in a future DSM
- •Level 1 children may receive autism or ADHD plus anxiety depending on the clinician
- •A diagnosis should exist to improve outcomes and services, whatever it is called
- 1:05:50 – 1:09:57
Overlap among autism, ADHD and anxiety
Sutcliffe describes how often the three conditions co-occur, noting that autism and ADHD could not be diagnosed together before 2013. She ties the overlap to the brain regions involved and explains that ADHD often has a "partner" condition.
- •About half of children with autism also have ADHD, and about 40 percent have anxiety
- •Executive functioning and anxiety are associated traits, not core autism criteria
- •Many children with autism have all three
- •ADHD often comes with anxiety, learning differences or oppositional behaviors
- 1:09:57 – 1:17:04
Oppositional behavior and the importance of understanding function
Sutcliffe explains why she avoids leaning on an ODD label and instead asks what is driving a child's oppositional behavior, such as anxiety, impulsivity, social difficulties or sensory overload. Attia compares this to medicine and adult psychiatry, where knowing the story guides treatment.
- •Oppositional behavior can stem from anxiety, untreated ADHD, social difficulties or sensory overload
- •There is no treatment for ODD as a label, but each underlying cause has its own treatment
- •Sutcliffe is transparent with families that labels are imperfect
- •Attia says adults seem to have better access to story-focused mental healthcare than children
- 1:17:04 – 1:25:08
Developmental-behavioral pediatrics and Sutcliffe's multidisciplinary clinic
Sutcliffe describes developmental-behavioral pediatrics as a young biopsychosocial specialty and recounts her path to founding Stanford's DBP presence and then her own clinic in 2014. She outlines the values behind it and the teams she built.
- •DBP was recognized as a subspecialty in 1999 and combines biology, mental health and social context
- •She left the traditional model to focus on health promotion, integrated teams and school collaboration
- •The family is treated as the patient, with strong emphasis on parent training
- •The clinic includes behavioral, mental health therapy, psychology testing and medical teams
- 1:25:08 – 1:36:21
ABA therapy: from discrete trial to naturalistic approaches
Sutcliffe explains what applied behavior analysis is, why discrete trial teaching is controversial, and how naturalistic methods such as pivotal response treatment train parents. They discuss coverage, siblings, and the quality problems that come with scaling the industry.
- •Discrete trial breaks skills into small, repetitive steps with reinforcers
- •Naturalistic ABA uses the child's environment and motivators, and PRT trains parents
- •Coverage varies by state; in California ABA is covered with an autism diagnosis
- •She recommends ABA done by well-trained people, but scaling to meet demand strains quality
- 1:36:21 – 1:43:51
Finding and evaluating care when no integrated clinic is nearby
Attia asks what parents outside major cities can do. Sutcliffe recommends starting with the pediatrician, building a team, and having someone act as a guide, and she lists qualities to look for in a provider. They note that this care must be integrated into the family's life where they live.
- •Start with the pediatrician and try to assemble a team
- •Families need someone to act as quarterback or Sherpa through changing priorities
- •Look for individualized thinking, proactive collaboration and parent training skills
- •Care is a years-long journey that must generalize to the child's real life
- 1:43:51 – 2:02:10
Treating ADHD: behavioral training, stimulants and non-stimulants
Sutcliffe explains her treatment approach by age, the weighing of risks and benefits, and the stimulant and non-stimulant options. She covers how stimulants work, common side effects, and how medication interacts with behavioral training and neuroplasticity.
- •Under six, first-line treatment is behavioral parent training; at six and older it is medication plus parent training
- •Methylphenidate and amphetamine families differ by formulation, and trying a few is needed to find the fit
- •Common side effects are lower lunchtime appetite and possible sleep onset issues; dose, timing or brand can be adjusted
- •Practicing skills while medicated may strengthen neural networks, and many patients eventually come off medication
- 2:02:10 – 2:09:25
Medication for children with autism, and the "superpowers" of level 1
Sutcliffe says no medication treats the core symptoms of autism, so medicines target specific behaviors such as hyperactivity, emotional dysregulation, anxiety or aggression. She then discusses the strengths seen in level 1 autism.
- •Medication is chosen by target symptom rather than label
- •Stimulants, non-stimulants and SSRIs may be used, and she rarely uses atypical antipsychotics herself
- •Strengths in level 1 include memory, attention to detail and rule-following
- •Perseverance and deep focus can suit technical fields
- 2:09:25 – 2:15:30
Key messages and closing the gap in care
Sutcliffe's main message is not to get stuck on labels, since definitions shift and each child is unique. She and Attia discuss what it would take to expand access, including training more people, reimbursement, and bridging health and education systems.
- •Overlap is large and labels can obscure the person beneath
- •Definitions have changed and will likely change again
- •More DBPs and allied professionals are needed, along with better reimbursement
- •Insurance and education systems each disclaim parts of intervention, so collaboration across them is needed
