330 – Autism, ADHD, and Anxiety: the rise in autism & an approach to diagnosing & treating children

1. 0:00 – 1:09

   Intro

   1. TSTrenna Sutcliffe0:00

      So it's really important to think about the why. It was actually one of the things when I, when I left, like, 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, 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, it's the, it's the journey afterwards, and it's really about personalized care.

   2. PAPeter Attia0:26

      Mm-hmm.

   3. TSTrenna Sutcliffe0:27

      And you can make such a big difference in child development, human wellbeing, by really understanding that specific child. And unfortunately, sometimes when you're on the treadmill-

   4. PAPeter Attia0:40

      Yep

   5. TSTrenna Sutcliffe0:40

      ... 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 know, "You have autism, here's a list of 15 recommendations. Good luck," and, "You have ADHD-"

   6. PAPeter Attia0:52

      Yep

   7. TSTrenna Sutcliffe0:52

      ... "here's a list of 15 recommendations. Good luck," without really getting to know the why behind that child's behavior.

   8. PAPeter Attia0:58

      [upbeat music] Hey, everyone, welcome to the Drive podcast. I'm your host, Peter Attia.

2. 1:09 – 8:53

   A passion for developmental-behavioral pediatrics (DBP), & the process of diagnosing anxiety, ADHD, & autism

   1. PAPeter Attia1:09

      Well, Trenna, thank you so much for coming all the way out to Austin. Um, 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, you know, frankly, this is just a topic that I think a lot of people are interested in. Obviously, many of them parents, but I, I just think people in general are kind of interested. Um, and so m- 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, um, you trained in pediatrics, developmental and behavioral, uh... Well, let's just, let me not try to summarize what you've done. Tell, tell me what you've done.

   2. TSTrenna Sutcliffe1:47

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

   3. PAPeter Attia2:24

      And your interests today primarily revolve around behavioral therapy for three things that we're gonna spend quite a bit of time talking about. Um, 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.

   4. TSTrenna Sutcliffe2:44

      Mm-hmm.

   5. PAPeter Attia2:45

      So coming at this through the lens of what you do today, which is running a really large, uh, successful multidisciplinary clinic, uh, for f- And I, I assume this is just for children, so this is up to 18 years old basically is your patient population?

   6. TSTrenna Sutcliffe3:01

      Correct.

   7. PAPeter Attia3:02

      Um, l- let's, let's start by just getting some of the, the, the sort of diagnostic criteria straight. I think that in general, most people listening to us have a gestalt for what each of those things are, but, uh, I think it would be helpful, uh, to maybe understand clinically how, how you look at each of those. So let's start with anxiety.

   8. TSTrenna Sutcliffe3:22

      Okay. Um, how I look at it clinically?

   9. PAPeter Attia3:26

      Yeah, and how is it defined, how, how, how clear are the diagnostic criteria, um, 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?

   10. TSTrenna Sutcliffe3:40

       Yeah, that's great. Those are great questions, Peter. So with all of these diagnoses, anxiety, ADHD, autism, uh, 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, um, diagnosing these conditions, um, trained in these conditions. But essentially, that person needs to be an expert on what the clinical picture looks like because there, 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.

   11. PAPeter Attia4:26

       Mm-hmm.

   12. TSTrenna Sutcliffe4:27

       Um, I have families come to me all the time, um, and I explain to them I have these clinical boxes and labels and diagnoses in my clinic, um, and these boxes and labels are essentially, like, man-made. We create these lists of criteria. But neurobiology in the brain is much more complex-

   13. PAPeter Attia4:48

       Mm-hmm

   14. TSTrenna Sutcliffe4:48

       ... than these, than these boxes. Um, 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. Um, ideally, we get to see the child in their real-life environment, so maybe even observing them in a real-life place like school, um, and then doing assessment in the clinic to collect information about them. Um, and with that, um, that clinician decides whether or not they meet, um, diagnostic criteria, a list of, of traits or characteristics described in a book called the DSM. Um, 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, is, for exam- example, anxiety. We all have feelings of anxiety. Anxiety's actually a very appropriate, normal feeling that we should all have, but it's all about How much impairment is it creating? How does imp- impact function, um, and impact someone doing their job? And for a child, their job is to learn and go to school, um, make friends, practice communicating and interacting with other peers, um, and be a positive contributor in their community, which is school. So it's about how these traits impact their function in that job.

   15. PAPeter Attia6:38

       What would you say is kind of the youngest age that each of those could be diagnosed? And I do wanna talk a little bit about-

   16. TSTrenna Sutcliffe6:46

       Yeah

   17. PAPeter Attia6:47

       ... the, what the layers of diagnostic, um, criteria are, but, but just sort of starting at the first question, which is, um, you know, if a parent says, "Hey, I think my child has such and such, I really wanna get a workup," is there a, is there an age beneath which you would say this, this might not be a good use of, of time and energy?

   18. TSTrenna Sutcliffe7:06

       Great question. So for autism, um, although the typical age for diagnosis is more like three or four, um, we can confidently make that diagnosis as young as 18 months of age.

   19. PAPeter Attia7:19

       Wow.

   20. TSTrenna Sutcliffe7:20

       Um, and I'll be honest, in the last 20 years, there's been one or two cases where I've made it, um, at 15 months of age, because it was very significant and obvious. Um, most often at that young age, we do wait a few more months to, to watch how the child develops because kids are a moving target.

   21. PAPeter Attia7:40

       Yep.

   22. TSTrenna Sutcliffe7:40

       Um, but with autism, it can be 18 months, two years of age, although half of the cases of autism are diagnosed over six. Um, with ADHD, um, you can make a diagnosis as young as four years of age. Uh, but again, I'll just tell you from my clinical experience, I rarely jump onto the diagnosis at, with a four or five-year-old because they're still a moving target, although I may start interventions-

   23. PAPeter Attia8:08

       Hmm

   24. TSTrenna Sutcliffe8:08

       ... like behavioral interventions and parenting support. Um, but there are a lot of four-year-olds who are pretty busy. Um, so I generally wait closer to school age, although technically you can make it as young as four.

   25. PAPeter Attia8:19

       So that would be for most kids, when you say school, you don't mean preschool, you mean actual kindergarten?

   26. TSTrenna Sutcliffe8:23

       Yeah, for most kids-

   27. PAPeter Attia8:24

       So five to, five to six.

   28. TSTrenna Sutcliffe8:25

       Five to six, I think.

   29. PAPeter Attia8:27

       Okay.

   30. TSTrenna Sutcliffe8:27

       Is I think, you know, a lot of people will wait till five or six to really see how that child is evolving. Um, although technically you could make it younger.
3. 8:53 – 16:45

   Anxiety & ADHD: assessing impairment & self-esteem & identifying anxiety & emotional well-being in young patients

   1. PAPeter Attia8:53

      Let's talk a little bit more about that. I don't know much about anxiety, and I'm guessing most people listening have, you know, sort of a, a, a sort of hand-waving sense-

   2. TSTrenna Sutcliffe9:01

      Yeah

   3. PAPeter Attia9:01

      ... of what it means.

   4. TSTrenna Sutcliffe9:02

      Yeah.

   5. PAPeter Attia9:02

      But, but, you know, you said separation anxiety as an example. Uh, anyone who's been a parent can appreciate moments of that.

   6. TSTrenna Sutcliffe9:10

      Yeah.

   7. PAPeter Attia9:10

      Um, 99% sure our puppy has separation anxiety.

   8. TSTrenna Sutcliffe9:15

      [laughs]

   9. PAPeter Attia9:15

      Uh, so, uh, what, what are some of the other types of anxiety, and how do you look to spot those in kids?

   10. TSTrenna Sutcliffe9:20

       Right. Right. Um, so again, just to emphasize, anxiety is actually an, a normal emotion-

   11. PAPeter Attia9:25

       Yeah

   12. TSTrenna Sutcliffe9:25

       ... that we should all have. So it's all about whether it's created enough impairment.

   13. PAPeter Attia9:28

       Right.

   14. TSTrenna Sutcliffe9:29

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

   15. PAPeter Attia10:50

       You've reiterated it twice now, which tells me how important it is. It-

   16. TSTrenna Sutcliffe10:53

       Yeah

   17. PAPeter Attia10:53

       ... it really has to come down to this impairment thing.

   18. TSTrenna Sutcliffe10:55

       It does.

   19. PAPeter Attia10:55

       And we clearly all have, um, all of us could probably read through the DSM-5 and place ourselves in each of these diagnostic buckets. I know I can.

   20. TSTrenna Sutcliffe11:05

       Yes.

   21. PAPeter Attia11:05

       Uh, I've done that exercise, and turns out I could make the case I have everything. But the truth of it is, what I, what I try to ask is, which is maladaptive? Um, which is mostly giving me kind of a negative response that is impacting relationships or work or these-

   22. TSTrenna Sutcliffe11:19

       Right

   23. PAPeter Attia11:19

       ... other things. So I, I like that framework for kids, right? Because if you think to yourself, "Oh, my kid has ADHD, but they're doing well in school."

   24. TSTrenna Sutcliffe11:27

       Mm-hmm.

   25. PAPeter Attia11:27

       "They're progressing in reading, writing, arithmetic. They enjoy playing sports. Yeah, maybe they're a little bit more rambunctious, but they have friends." Like, how would you help a parent sort of navigate that if they, if they came to you and said, you know, "I think my son or my daughter has ADHD," like what are kind of the, the impairment style questions you would be asking to, to sort of paint the contours of this condition, even if you acknowledge that, boy, that, that, that kid's got a lot of energy?

   26. TSTrenna Sutcliffe11:56

       Yeah. Right. Um, so that's, that, those are great questions because it is definitely a, a spectrum, a normal-- There's a bell curve.

   27. PAPeter Attia12:02

       Yeah.

   28. TSTrenna Sutcliffe12:03

       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, um, leave the, uh, this is sort of like, uh, leaving the average range, the typical, uh, 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 'cause I think they're just like learning differences and thinking differences as well.

   29. PAPeter Attia12:25

       Mm-hmm.

   30. TSTrenna Sutcliffe12:26

       Um, 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. And how people-- H-how is it impacting that child's self-concept, how they see themselves? Um, how is it impacting their relationships with peers? That's another key one. So, um, um, does it impact social interactions? Does it impact how they connect with peers? Does it impact the feedback they're getting from peers? Um, 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? Um, the self-esteem thing is very important to me, though. And so for a child who has a biologic condition, 'cause this is-- 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're-- they, they are worried they're not doing, you know, 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-
4. 16:45 – 28:32

   Evolving diagnosis of autism: the spectrum & individual needs

   1. PAPeter Attia16:45

      So you've, in that description, actually m-made a pretty clear, I think, um, case for some of the traits that are showing up in ADHD and in, um, anxiety-

   2. TSTrenna Sutcliffe16:57

      Mm-hmm

   3. PAPeter Attia16:57

      ... all the different variants of it. Um, let's talk a little bit more about autism. Now, of course, it is referred to as ASD, right?

   4. TSTrenna Sutcliffe17:06

      Correct.

   5. PAPeter Attia17:06

      Autism spectrum-

   6. TSTrenna Sutcliffe17:07

      Autism spectrum disorder

   7. PAPeter Attia17:08

      ... spectrum disorder. Uh, we'll, we'll park for a moment the, the, the use of the word-

   8. TSTrenna Sutcliffe17:14

      Yeah

   9. PAPeter Attia17:14

      ... disorder and maybe come back to that a little bit. But, um, tell me, today, how is the diagnosis of autism made? Because I think when many people think of autism, you know, if they're old enough, they might think of Rain Man, right?

   10. TSTrenna Sutcliffe17:28

       Yeah.

   11. PAPeter Attia17:29

       You're gonna 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, um, and things of that nature. But, but again, given the nature of this and the fact that it's a spectrum, um, it, it-- that must make it even more challenging to find the diagnosis, correct?

   12. TSTrenna Sutcliffe17:59

       Very, very. Um, so, uh, I have so much to say about autism, right, about the diagnosis and how we make it and how it's changed so much over the years. Um, so autism spectrum. So first, it's a spectrum, huge spectrum of what those, what this means when we, when we talk about autism spectrum. Um, uh, the-- It goes from, um, what people remember it from decades ago as from, you know, non-verbal, very little, you know, communication skills, um, being somewhat isolated, not interacting with other people, mannerisms such as flapping your hands. Very-- That's sort of a classic description that we do remember. Um- From, you know, over the last couple decades, um, nowadays, uh, many children who have a lot of speech and language skills, who c- who are, who do communicate a lot, but st- struggle with the social communication that we have with each other, um, who have many, many strengths but do struggle with social skills and do have some restricted interests or repetitive behaviors, they also qualify under this umbrella term called autism spectrum disorder. And this term, autism spectrum disorder, that term came out in, uh, 2013 with the DSM 5. Um, so how we diagnose it, um, is based on, again, clinical traits, but the definition and those, and the checklists of those traits have actually changed many times-

   13. PAPeter Attia19:38

       Yeah

   14. TSTrenna Sutcliffe19:38

       ... over the last few decades. Um, so currently it is, uh, you work with an, uh, an expert who has a lot of experience with autism, and they do an analysis of someone's behavior. Um, and the two areas that we look at are social communication skills, and the other is the repetitive behaviors, restricted interests. So for social communication skills, um, our current diagnostic criteria requires that a, that a patient has differences, uh, in three specific areas. Um, one is their social reciprocity. So this is the, um, back and forth of social interactions. It's how do you initiate socially, how do you respond socially. The second area is related to non-verbal communication skills. So it's how someone uses their, uh, non-verbal communication, uh, eye contact, gestures, as well as how they understand, um, and interpret somebody else's non-verbal communication. Um, and then the third area is related to how they understand relationships. So it's about building friendships, playing with peers, um, um, how they understand the social context of, of being in a group. Um, so those are the three key areas, um, 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.

   15. PAPeter Attia21:23

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

   16. TSTrenna Sutcliffe21:28

       Great question. Um, depends on the level of severity, uh, in the child. Um, so first of all, it's important that whoever's doing the assessment really understands that child.

   17. PAPeter Attia21:40

       T- tell me again what type of pr- is this something... Like, who in your clinical team-

   18. TSTrenna Sutcliffe21:45

       Yeah

   19. PAPeter Attia21:45

       ... does this? What type of training does this person have? Is it a physician? Is it, um, a, a social sci- like-

   20. TSTrenna Sutcliffe21:51

       Yeah. Great question. Um, it can be, it can be a physician or it can be a psychologist. Those are-

   21. PAPeter Attia21:57

       Okay

   22. TSTrenna Sutcliffe21:57

       ... that's generally who does it. So physician, it would either be a, a developmental behavioral pediatrician, um, or a psychiatrist. That's most often. Occasionally it's a pediatric neurologist, um, or somebody else, uh, in, um, with some sort of similar background and training. Um, but generally DBP or psychiatrist. And then, um, and if it's not a physician, then it's a psychologist that usually does the assessment. And so, um, uh, the assessment could be multiple things. Um, there's no, uh, there's no gold standard like the assessment has to include, um, 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. Like the label is only one piece of it. To me, if someone tells me their child has autism, I actually really don't know much about their child.

   23. PAPeter Attia22:49

       Hmm. Say more.

   24. TSTrenna Sutcliffe22:51

       I, I, that, 'cause you tell me your child has autism, I have, I really don't know what your child is like if someone tells me that on the street. And so, um, so, and again, like 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, you know, 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, the assessment, like there's t- there's, there's multiple goals with the assessment. One part of the assessment is to make a diagnosis, um, 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, um, and work on skill building. It can help get resources at school or through insurance. So there, the, the diagnosis is a tool. However, to really make a difference, you wanna 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, um, more significant case, um, with significant impairments, we frequently can make the diagnosis. I'll just be honest, you can make it pretty quickly. Um, you, you should take a good history.

   25. PAPeter Attia24:25

       Hmm.

   26. TSTrenna Sutcliffe24:25

       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.

   27. PAPeter Attia24:38

       Yeah.

   28. TSTrenna Sutcliffe24:39

       It'd be obvious to you if you were in a restaurant-

   29. PAPeter Attia24:41

       Sure

   30. TSTrenna Sutcliffe24:41

       ... you saw someone with autism. You know, it's obvious to many people.
5. 28:32 – 41:40

   Dramatic rise in autism spectrum disorder (ASD): genetics, environment, expanded diagnostic criteria

   1. TSTrenna Sutcliffe28:32

      very broad.

   2. PAPeter Attia28:33

      Now this is a question I'm sure you get asked all the time. So the CDC said in the year two thousand, one in, uh, roughly two hundred kids, one hundred fifty to two hundred kids had autism. Now of course, that's pre this change of the, the DSM-V, so we can only take that to mean that those were the kids in that, in that bucket of more extreme autism that did not include the PDD-NOS. Was that what the other one was called?

   3. TSTrenna Sutcliffe29:00

      Yeah.

   4. PAPeter Attia29:00

      Yeah.

   5. TSTrenna Sutcliffe29:00

      Correct.

   6. PAPeter Attia29:00

      And, and Asperger's. Um, but if you, if you look at the data up until, you know, prior to that change, the last year prior to that change in twenty twelve, it was down from one in, um, one fifty to one in sixty-nine.

   7. TSTrenna Sutcliffe29:16

      Yeah.

   8. PAPeter Attia29:17

      So in other words, there was something that was increasing the prevalence or diagnosis by about a factor of two. Then we get the change in the DSM, and today we're at one in thirty-six. 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, uh, bucket included and a, a, a larger net cast around it?

   9. TSTrenna Sutcliffe29:50

      Yeah, that's a great question. I can't believe it's one in thirty-six, because I've been doing this in-- for twenty-five years. I can never keep track of the numbers. I always-- Every time I went to, every time I go to an annual meeting, the number changes.

   10. PAPeter Attia30:02

       Yeah.

   11. TSTrenna Sutcliffe30:03

       Um, and it is one in thirty-six now that we diagnose.

   12. PAPeter Attia30:05

       Well, again, that's, that's what the CDC said in twenty twenty.

   13. TSTrenna Sutcliffe30:07

       Correct. Yeah.

   14. PAPeter Attia30:08

       So I'm gonna, I'm gonna go with whatever numbers you take.

   15. TSTrenna Sutcliffe30:10

       Yeah.

   16. PAPeter Attia30:10

       I, I'll, I'll believe your numbers more than mine.

   17. TSTrenna Sutcliffe30:12

       [laughs] Um, the point being that it-- the numbers has cha-- 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. Um, but people in the field, uh, believe that, um, those changes don't explain the drastic changes in the numbers. Um, and there has to be something else involved. Um, 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, um, in, in increasing the rate of autism, uh, in our population.

   18. PAPeter Attia31:03

       So 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?

   19. TSTrenna Sutcliffe31:12

       Sure.

   20. PAPeter Attia31:12

       Let's put the diagnostic criteria aside. Let's put the, you know, keys under the lamppost aside, meaning, you know, wherever there's more attention, you're gonna see more things. Um, what are, what are, what are some of the environmental things that you think could be amplifying this?

   21. TSTrenna Sutcliffe31:29

       Yeah. Um, there is thoughts around pollution, um, maternal, uh, infection, prolonged fever during pregnancy, the health of the placenta, stress, uh, parental age. There is a lot of environmental factors that have been implicated. But what I want to say is that, so just to take a step back first then, just, just kind of talk about the cause of autism, like the genetics and the environmental piece.

   22. PAPeter Attia32:02

       Mm-hmm.

   23. TSTrenna Sutcliffe32:02

       So just to make it really clear, like 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 sort of like a, a 10 hit model, meaning like, um, and I-- that we don't know that the number's 10, but the idea that there's multiple things-

   24. PAPeter Attia32:30

       It's not a two-hit model.

   25. TSTrenna Sutcliffe32:31

       It's not a two-hit model. It's, uh, 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.

   26. PAPeter Attia32:51

       Let's start with the genetic piece.

   27. TSTrenna Sutcliffe32:53

       Yeah.

   28. PAPeter Attia32:53

       So 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.

   29. TSTrenna Sutcliffe33:01

       Mm-hmm.

   30. PAPeter Attia33:01

       But maybe just for folks that are-- need to brush up on that-
6. 41:40 – 46:22

   Exploring epigenetics & the potential multigenerational impact of environment exposures on susceptibility

   1. TSTrenna Sutcliffe41:40

      Um, with epigenetics, as you know, it can be, you know, epigenetic changes, which just to clarify for everybody, uh, it's, the, the DNA sequence is not changed. It's about, uh, tags on the DNA that can change the expression of genes or proteins called histones that, um, are changed that, uh, end up resulting in changed gene expression. But the, the changed gene expression can actually be inherited or passed through generations as well.

   2. PAPeter Attia42:10

      Yeah, I was gonna ask you about that. Can, c- is that, do we know that to be a fact, that the epigenome is being transmitted?

   3. TSTrenna Sutcliffe42:17

      I think it's controversial.

   4. PAPeter Attia42:18

      Yeah.

   5. TSTrenna Sutcliffe42:18

      Um, I think it's controversial, but there is some thought about that, about the idea of a, um, the germ cells, uh, in a fetus, um, in a grandparent being exposed to smoking, toxins, ch- ch- 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.

   6. PAPeter Attia42:52

      It makes a ton of sense to me-

   7. TSTrenna Sutcliffe42:53

      Yeah

   8. PAPeter Attia42:53

      ... because I think about this problem night and day. I do wanna make sure the listeners understand that, um, well, first of all, this is not established yet.

   9. TSTrenna Sutcliffe43:00

      Not at all. Not at all.

   10. PAPeter Attia43:01

       Um, and I wanna make sure they understand-

   11. TSTrenna Sutcliffe43:02

       Yeah

   12. PAPeter Attia43:02

       ... what we're saying. So let- let's, let's explain it one more time. So we have these four things that make up DNA, right?

   13. TSTrenna Sutcliffe43:09

       Mm-hmm.

   14. PAPeter Attia43:09

       Your C, G, A, and T, and that is the code. That is the code of life.

   15. TSTrenna Sutcliffe43:13

       Yeah.

   16. PAPeter Attia43:13

       Um, but on the backbone of those things, you can put little methyl groups-

   17. TSTrenna Sutcliffe43:18

       Mm-hmm

   18. PAPeter Attia43:18

       ... which is just a little carbon with three hydrogens Uh, and that's called epigenetics. And by the way, we're all born with methylated groups all over our epigenome, back of the genome, right? Um, over life, we know that changes. So we know that simply aging changes methylation. Um, 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 differ- differential gene expression in different tissues.

   19. TSTrenna Sutcliffe43:54

       Yeah.

   20. PAPeter Attia43:54

       So the question, the jugular question is, if you have a methylation pattern and you pass-- 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? I mean, at that point, methylation would start to be-- epigenetics would start to become genetic.

   21. TSTrenna Sutcliffe44:23

       Mm-hmm.

   22. PAPeter Attia44:23

       Right? It starts to become a part of the germline.

   23. TSTrenna Sutcliffe44:25

       Mm-hmm.

   24. PAPeter Attia44:26

       Um, so I mean, this is an answerable question, by the way, in my book. Like, when I think of things that we should know the answer to-

   25. TSTrenna Sutcliffe44:33

       Yeah

   26. PAPeter Attia44:33

       ... in a decade-

   27. TSTrenna Sutcliffe44:33

       Yeah

   28. PAPeter Attia44:33

       ... I'm gonna put this in the list of things-

   29. TSTrenna Sutcliffe44:35

       Yeah

   30. PAPeter Attia44:35

       ... that we should know the answer to, just based on the fact that we have a-- we, we will have enough longitudinal data-
7. 46:22 – 54:20

   Evolution of autism classifications, & the particular challenges for children with mildautism due to a lack of support

   1. PAPeter Attia46:22

      And do you ever worry that, you know, if this epidemic-- Look, what's to say this isn't gonna get to be one in three kids-

   2. TSTrenna Sutcliffe46:33

      Right

   3. PAPeter Attia46:33

      ... in thirty years? And are there enough people like you that are going to be able to help, uh, parents and help families and help children with that? So, so that, that, that, I, I don't wanna sound alarmist-

   4. TSTrenna Sutcliffe46:44

      Yeah

   5. PAPeter Attia46:44

      ... but I worry when we have an epidemic potentially and we don't have a great sense of causality.

   6. TSTrenna Sutcliffe46:51

      Yeah. Um, that's profound. I'm try-- And, uh, and it's, it's imp-- And I'm thinking about a number of different things. One, I'm thinking about, 'cause you're talking about this one in three.

   7. PAPeter Attia47:02

      And I'm just throwing that out-

   8. TSTrenna Sutcliffe47:03

      Yeah

   9. PAPeter Attia47:04

      ... as, "Hey, what if this trend continues," right?

   10. TSTrenna Sutcliffe47:05

       Yeah. And so one of the issues, though, is the, how we define-

   11. PAPeter Attia47:10

       Yeah

   12. TSTrenna Sutcliffe47:10

       ... the condition. That's the thing. That's, is-- So there is still that. I, although I believe that there is this piece with genetics and the environment and how we are evolving, and there's this f-- it's a phenotype. So a phen-- It's how we-- This phenotype where there's differences in how, in, in social communication skills and repetitive behaviors of restricted interests, this phenotype is, uh, which is on a huge spectrum as well. I just wanna make sure this is the thing. It's a-- 'Cause the, when we're talking about these numbers, like one in thirty-six and this number continuing to increase, it's not just the kids who are, like, nonverbal autism.

   13. PAPeter Attia47:51

       Right. Sure.

   14. TSTrenna Sutcliffe47:51

       It's this really wide phenotype is increasing. Um, and so it is important we understand the cause of why this phenotype is increasing and then, um, what should we or should not be doing about that.

   15. PAPeter Attia48:08

       What do you know about the, um, change in the, uh, frequency or the prevalence of, let's pick one subset of that, which is, you know, the nonverbal or chi-child that is so impaired that I could diagnose them-

   16. TSTrenna Sutcliffe48:26

       Yeah

   17. PAPeter Attia48:26

       ... or a parent could diagnose them.

   18. TSTrenna Sutcliffe48:28

       Right. Uh-

   19. PAPeter Attia48:28

       Do we know if that has remained relatively constant over the last twenty-five years despite the change in diagnostic criteria?

   20. TSTrenna Sutcliffe48:37

       I believe there's an increase in that number as well. Um, but the numbers that are put out there, the really profound numbers actually describe the entire spectrum.

   21. PAPeter Attia48:47

       Yeah.

   22. TSTrenna Sutcliffe48:47

       And, um, they don't actually subdivide into the, the different parts, uh, of the spectrum.

   23. PAPeter Attia48:54

       Do you have a ballpark idea? So if the overall diagnosis of autism is increased, you know, fivefold, uh, in, in the last twenty years-

   24. TSTrenna Sutcliffe49:04

       Yeah

   25. PAPeter Attia49:04

       ... has that more severe part gone up by fifty percent, by a hundred percent? I mean, what's the-- what do you think it is, or what do you know it is?

   26. TSTrenna Sutcliffe49:12

       We subdivide autism spectrum into three, into three buckets, level one, level two, level three.

   27. PAPeter Attia49:17

       Uh-huh.

   28. TSTrenna Sutcliffe49:17

       So the more significantly impaired children would fall into level three-

   29. PAPeter Attia49:23

       Mm-hmm

   30. TSTrenna Sutcliffe49:23

       ... where they require very substantial support. But in, there are very few research studies that actually look into these subbuckets. And, um, and I have to be honest, I'm not sure clinicians are always great at, um, identifying kids in the subbuckets either. Like you and I are talking about a very specific, you know, profile that should be very obvious to identify, but there's other kids in subbucket three that are sometimes put in subbucket two depending on what clinician they see.
8. 54:20 – 1:05:49

   Broadening of the autism spectrum: benefits/risks of expanded diagnostic criteria & the need to focus on better outcomes

   1. TSTrenna Sutcliffe54:20

      level one.

   2. PAPeter Attia54:21

      Help me understand the natural history of those kids back in the '70s and '80s, right? So back, back in the '70s-

   3. TSTrenna Sutcliffe54:27

      Yeah, yeah

   4. PAPeter Attia54:27

      ... and '80s when you and I were kids-

   5. TSTrenna Sutcliffe54:28

      Yeah

   6. PAPeter Attia54:29

      ... um, nobody thought anything of those kids, right?

   7. TSTrenna Sutcliffe54:31

      Mm-hmm.

   8. PAPeter Attia54:31

      They weren't, they weren't gonna c- certainly weren't gonna get labeled with autism. They certainly weren't gonna show up with, uh, you know, in-school programs to help them-

   9. TSTrenna Sutcliffe54:40

      Yeah

   10. PAPeter Attia54:40

       ... 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 gonna struggle in school. But there's, there's clearly something that, that they're struggling with.

   11. TSTrenna Sutcliffe54:51

       Right.

   12. PAPeter Attia54:52

       Do, I don't know if we, I mean, I don't, obviously this hasn't been studied, but I'm very curious based on your experience and your judgment, like 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? Like how did those people, what was the natural history of them? There are clearly a lot of them.

   13. TSTrenna Sutcliffe55:10

       There are. There are a lot of them. Um, and I think, uh, they did, they found a path that made sense to them. They obviously learned what their strengths were, and their strengths may have been around memory, uh, you know, detail-oriented, um, following rules that are black and white. Um, they may have had really wonderful cognitive skills, um, um, in certain areas that were less around inferring and social skills and more concrete. Um- And yeah, my, we don't have studies to-

   14. PAPeter Attia55:48

       Yeah

   15. TSTrenna Sutcliffe55:48

       ... to say this for sure, but my guess is they have lived happy, successful lives. Uh, a, a lot of them, some of them, um, doing things that they enjoy doing and are passionate about. They probably have found ways to not engage in large social, uh, settings. Um, but there's a lot of careers out there that are a good match, and they also have relationships and marriages. I just wanna emphasize that. People with autism get married.

   16. PAPeter Attia56:15

       I, I think it's, I mean, I just think-

   17. TSTrenna Sutcliffe56:17

       Yeah

   18. PAPeter Attia56:17

       ... there's zero chance that there aren't thousands if not tens of thousands of these people listening to us right now.

   19. TSTrenna Sutcliffe56:23

       Yeah.

   20. PAPeter Attia56:23

       Right? Because they're, they're adults today, and I wonder if they're listening to some of this and they're saying, "This resonates," like, "I get that."

   21. TSTrenna Sutcliffe56:30

       Yeah.

   22. PAPeter Attia56:30

       You know, "When I was a kid, I was hyper-focused on this stuff."

   23. TSTrenna Sutcliffe56:32

       Yeah.

   24. PAPeter Attia56:33

       "I wasn't interested in a whole bunch of stuff."

   25. TSTrenna Sutcliffe56:35

       Yeah.

   26. PAPeter Attia56:35

       Um, "It was a little harder for me to interact with other kids and, and things like that, and, and yet I found my path and here I am today."

   27. TSTrenna Sutcliffe56:42

       Yeah. 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, uh, at some point-

   28. PAPeter Attia56:55

       [laughs]

   29. TSTrenna Sutcliffe56:56

       ... while I develop this relationship with the family, the parents say, "Gosh, uh, so much of my child is in me. I s- as you are describing my child and my child's strengths and challenges, and I, I see me, and this is exactly what I went through when I was young." And then they share how hard it was.

   30. PAPeter Attia57:15

       Hmm.
9. 1:05:49 – 1:09:57

   Overlap between ASD, ADHD, & anxiety

   1. PAPeter Attia1:05:49

      Um, before we get into more of the details about what you do specifically treatment-wise, I wanna finish one other bit of, uh, the, the, the sort of diagnosis piece, which is can you talk a little bit about the overlap? You just did it sort of a second ago-

   2. TSTrenna Sutcliffe1:06:05

      Hmm

   3. PAPeter Attia1:06:05

      ... about, uh, ASD, ADHD, and anxiety. How often do they overlap? What do those Venn diagrams look like?

   4. TSTrenna Sutcliffe1:06:13

      Yeah. That's a great question. Okay. Um, so I'm gonna start off by saying, okay, we ha- we, we diagnose anxiety in kids, and there's that bucket, and there's many kids who just clearly fall in the anxiety bucket and, and, um, 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 gonna focus on the autism bucket, uh, first. So, um, 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, you can find reports for anywhere from like, you know, forty percent to seventy percent of kids, but we say about half of kids with autism actually do have a diagnosis of autism. Interestingly, before the DSM 5, before twenty thirteen, we were not allowed to give both those diagnoses together. So they were mutually exclusive. If a child had autism, we, we did not give a diagnosis of ADHD. So starting in twenty thirteen, 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 forty percent of kids with autism also have anxiety. And this makes sense when you think about the parts of the brain involved. Like when you think about ADHD, we're thinking about executive functioning skills, we're thinking about prefrontal lobes. Um, 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. Um, but kids with autism do have challenges with executive functioning, um, and anxiety, although those are not part of the diagnostic criteria. So those are associated symptoms, associated traits, associated diagno- diagnoses, so they're comorbidities, um, not part of the core diagnostic criteria, but there's a lot of overlap.

   5. PAPeter Attia1:08:32

      If 50% of them have ADHD and 40% of them also ca- pardon me, yeah-

   6. TSTrenna Sutcliffe1:08:38

      Yeah

   7. PAPeter Attia1:08:38

      ... carry a diagnosis of anxiety, is there a percent of those that are overlapped and have all three?

   8. TSTrenna Sutcliffe1:08:42

      Yeah. I'll say a lot of them have all three. Yeah, so-

   9. PAPeter Attia1:08:45

      And what's, w- uh, what is that, roughly?

   10. TSTrenna Sutcliffe1:08:46

       I don't know the exact number for that one.

   11. PAPeter Attia1:08:47

       Okay. Okay.

   12. TSTrenna Sutcliffe1:08:48

       But there is a, this is the thing, that these kids have, um, they present with the core features of autism along with the executive functioning challenges and are anxious.

   13. PAPeter Attia1:09:01

       Okay. So now what can we say about kids with ADHD and anxiety?

   14. TSTrenna Sutcliffe1:09:06

       Yeah.

   15. PAPeter Attia1:09:06

       What's that overlap?

   16. TSTrenna Sutcliffe1:09:07

       Yeah. So, um, so kids who have ADHD and anxiety, d- they, their numbers towards autism are not as high.

   17. PAPeter Attia1:09:16

       Mm-hmm.

   18. TSTrenna Sutcliffe1:09:16

       So there are a lot more kids with ADHD who don't go on to having, who are not diagnosed with, with autism.

   19. PAPeter Attia1:09:22

       Yes.

   20. TSTrenna Sutcliffe1:09:22

       But there's a lot of overlap between ADHD and anxiety. So ADHD frequently has a partner, is what I tell families.

   21. PAPeter Attia1:09:29

       Mm.

   22. TSTrenna Sutcliffe1:09:29

       Um, if you have ADHD, you often have either s- anxiety or some other mood challenges, um, or you have learning differences. So learning disabilities are frequently, uh, present to kids with ADHD. Um, or you have oppositional behaviors.

   23. PAPeter Attia1:09:49

       Mm.

   24. TSTrenna Sutcliffe1:09:50

       Um, so there's often a, a second condition present in kids with ADHD.

10. 1:09:57 – 1:17:05

    Understanding oppositional defiant disorder, & the importance of understanding the “why” behind a behavior

    1. PAPeter Attia1:09:57

       Say more about oppositional-

    2. TSTrenna Sutcliffe1:09:58

       Yeah

    3. PAPeter Attia1:09:58

       ... behavioral tendencies.

    4. TSTrenna Sutcliffe1:10:00

       Yeah. So there is a diagnosis out there called oppositional defiant disorder, and that is a diagnosis that I don't use, um, quickly or often, uh, in young kids when I see oppositional behaviors. Um, this is my personal approach, um, is that I will say I see a child with oppositional behaviors. Um, what does that mean? Means someone who argues, doesn't follow rules, um, disobeys, um, s- lies. Um, so kids with these types of behaviors, I wanna understand the why s- before I jump into saying that they have oppositional defiant disorder. Technically, you know, maybe they meet the criteria. Again, it's a checklist-

    5. PAPeter Attia1:10:49

       Yeah

    6. TSTrenna Sutcliffe1:10:49

       ... the 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 O- ODD," we call it. It's like, how does that help me? What do I do with that? Um, 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, you know, we all, we all have seen kids who, you know, 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 contexts and social skills. They actually have trouble with their social reciprocity, but they're presenting with what looks like oppositional behavior. Um, that child may be sensory overloaded and have challenges processing sensory information, um, and therefore becomes overwhelmed and dysregulated and oppositional. So I, the list goes on.

    7. PAPeter Attia1:12:03

       Yeah.

    8. TSTrenna Sutcliffe1:12:04

       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, "Okay, well, okay, now what?"

    9. PAPeter Attia1:12:15

       Yeah. I wanna come actually right back to that 'cause I really, I think that's just a... I mean, I don't know what fraction of, of kids are getting that type of insight and attention, but my concern would be not enough, right?

    10. TSTrenna Sutcliffe1:12:29

        Yeah.

    11. PAPeter Attia1:12:29

        My concern would be that these things just, we're just, we're just in a world of ever-expanding labels-

    12. TSTrenna Sutcliffe1:12:35

        Yes

    13. PAPeter Attia1:12:35

        ... and, and codes, and the "so what" is missing.

    14. TSTrenna Sutcliffe1:12:40

        Yeah.

    15. PAPeter Attia1:12:40

        When, of course-

    16. TSTrenna Sutcliffe1:12:41

        Yes

    17. PAPeter Attia1:12:41

        ... there isn't really a field of medicine in which the "so what" matters more, right?

    18. TSTrenna Sutcliffe1:12:47

        I agree.

    19. PAPeter Attia1:12:47

        Like, if you think about, um, this person has hypertension, hyperlipidemia, insulin resistance, it's important to understand why.

    20. TSTrenna Sutcliffe1:12:55

        Yeah.

    21. PAPeter Attia1:12:55

        But at a minimum, we have great treatments if we don't know the why.

    22. TSTrenna Sutcliffe1:12:59

        Yeah.

    23. PAPeter Attia1:12:59

        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.

    24. TSTrenna Sutcliffe1:13:05

        Yeah.

    25. PAPeter Attia1:13:06

        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 [lip smack] you know, a lot of people would be, would be hesitant to give their kids medication here. I wanna talk, of course, about this-

    26. TSTrenna Sutcliffe1:13:19

        Yeah

    27. PAPeter Attia1:13:19

        ... in, in length. Um, which is all the more reason why, boy, if you don't understand why this kid has oppositional defiant disorder, if it's, 'cause if it's-

    28. TSTrenna Sutcliffe1:13:28

        Yeah

    29. PAPeter Attia1:13:28

        ... like sensory overload-

    30. TSTrenna Sutcliffe1:13:30

        Yeah
11. 1:17:05 – 1:25:08

    Defining developmental-behavioral pediatrics (DBP)

    1. TSTrenna Sutcliffe1:17:05

       about developmental behavioral pediatrics, which, by the way, is a very young specialty, and there's-

    2. PAPeter Attia1:17:10

       You were the first person at Stanford, uh-

    3. TSTrenna Sutcliffe1:17:13

       I, I was

    4. PAPeter Attia1:17:13

       ... in that, in that, in that group. That, that, you created the group.

    5. TSTrenna Sutcliffe1:17:16

       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 a, what we call a biopsychosocial specialty. And so what that means is we think about the biology. So 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 wellbeing as well as the mental wellbeing. Um, and then the social piece is the fact that we, 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 wellbeing and health than to start early on-

    6. PAPeter Attia1:18:12

       Yeah

    7. TSTrenna Sutcliffe1:18:12

       ... and impact child development and behavior and self-esteem and learning. Um, but 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, you know, family dynamics, parenting, school and education. Like, this is key. Like, this is the bridge between education and medical health, which honestly is, is hard to do in the traditional medical model, bridging to education, but, but 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, to support child development and behavior, whether there's a diagnosis or not.

    8. PAPeter Attia1:19:01

       Let's talk a little bit about your journey be-

    9. TSTrenna Sutcliffe1:19:03

       Mm-hmm

    10. PAPeter Attia1:19:03

        ... you know, you, you, um, you got to Stanford in '04.

    11. TSTrenna Sutcliffe1:19:07

        Yeah. My husband got there in '04. I was there in, just in '05, I arrived in '05. So I, uh, so I did my DBP, uh, training at the Hospital for Sick Children in Toronto, so I'm Canadian. Uh, trained at SickKids, an incredible place to train with volume of ca- of cases and complexity of cases. So it was a fantastic place. Um-

    12. PAPeter Attia1:19:29

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

    13. TSTrenna Sutcliffe1:19:32

        Yeah. It is, it is. It is a fantastic place to, to train. Um, and so I did pediatrics, pediatric neurology, and developmental behavioral pediatrics there. My interests were always, my interests and passions were always, like, genetics, the human brain, developing human, um, neuroplasticity.

    14. PAPeter Attia1:19:50

        Mm-hmm.

    15. TSTrenna Sutcliffe1:19:50

        I did a lot of research in neuroplasticity. Um, and then, um, 20 years ago, moved to California, and in the Bay Area, and took a job at Stanford. But the field of DBP was brand new. So as I said, like it is, it was just starting out, so they did not have a developmental behavioral pediatrician yet at Stanford. Um, so I was the first there. After me, um, 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. Um, but I arrived, there, there was nobody else. Um, I was at Stanford for a number of years and did research, um- Clinical work as well as medical education teaching. Um, 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, um, and start my own, uh, multidisciplinary clinic.

    16. PAPeter Attia1:20:53

        Tell me a little bit more about why. What, what were you-

    17. TSTrenna Sutcliffe1:20:55

        Yeah

    18. PAPeter Attia1:20:55

        ... what was happening prior to 2014 that you didn't enjoy?

    19. TSTrenna Sutcliffe1:21:00

        Yeah. I, I felt that I could help my families and pa- and patients more and/or differently. I felt like I, I wanted to make an impact. That's one of my, my passions is always to make a difference, and I, I felt that I was a little bit stuck in the model. Um, and it's just, you know, the medical model, it's, it's, uh, there's so many good things about it, but I had to, to, to, to help the families the way I wanted to, uh, with my values, which I, which I can describe, I, I needed to leave. And what did I value? So one, um, I believe in promoting, like, health and well-being, and, and that's all about DBP, development and behavior. It's about promoting health. Where medical centers are, uh, have been in the past primarily focused on treating disease.

    20. PAPeter Attia1:21:54

        Mm-hmm.

    21. TSTrenna Sutcliffe1:21:54

        Um, so that was one thing. Uh, two, I really believe in, um, multidisciplinary teams and really having an integrated team. Um, [lips smack] uh, in this area, as I described, like understanding the whole child requires not just a physician, requires therapists, psychologists, teachers, like different types of professionals. And I really believe that to make a difference, those professionals have to be integrated. Um, if you want a, a touchdown, like all the players need to be reading the same playbook. Um, 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 therapist, and, um, we had all these different silos. So I really believed I needed to bring the silos together. Um, another thing is I believe in community collaboration, so that's actually the bridge to education, and that, uh, that's actually really hard to do in a standard medical model is to really have, um, collaboration with the school. So now I, 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.

    22. PAPeter Attia1:23:06

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

    23. TSTrenna Sutcliffe1:23:07

        I need to see-

    24. PAPeter Attia1:23:07

        Yeah

    25. TSTrenna Sutcliffe1:23:07

        ... what they look like at school. Um, and then I believe that the family is the patient, not just the child. So that's also, uh, if I am gonna 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 working with the f-... and, and again, this is the social piece, the dynamics. Understanding the whole family situation is really important to make a difference in a child. Um, and then lastly, I believe in, um [lips smack] I love learning and being innovative and thinking outside the box. And so I decided to, um, set something up where I can continue to, like, ask questions and challenge the system and, and try to make it better.

    26. PAPeter Attia1:23:55

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

    27. TSTrenna Sutcliffe1:23:58

        So we have, um, we have a few different programs. We have, um, we have a behavioral team, um, where we focus mostly on kids with, um, with autism. However, probably about 20% of the kids who work with our behavioral team, um, don't have a diagnosis of autism but do benefit from behavioral therapy, social skill groups, um, parent training that focuses on behavioral models. Um, we have a mental health therapy team, um, that supports kids with and teenagers with anxiety, depression. So we offer different types of therapy-

    28. PAPeter Attia1:24:33

        Hmm

    29. TSTrenna Sutcliffe1:24:33

        ... for that, mood, uh, dysregulation, ADHD. We have psychologists who do testing for, um, to, for diagnostic assessment. Um, and then, um, and then we have a medical... I'm the medical team where we... But it's, 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, um, the therapies, the parenting, the school piece, and medication when it's important and can help.

12. 1:25:08 – 1:36:21

    Updated methods of ABA (applied behavioral analysis) therapy: evolution, controversies, challenges of scaling autism care, & tailored interventions

    1. PAPeter Attia1:25:08

       So there's something called ABA.

    2. TSTrenna Sutcliffe1:25:10

       Mm-hmm.

    3. PAPeter Attia1:25:10

       What... Tell me again. Remind me what it stands for.

    4. TSTrenna Sutcliffe1:25:12

       Applied behavioral analysis.

    5. PAPeter Attia1:25:14

       Okay. And my... It seems to be a somewhat polarizing topic-

    6. TSTrenna Sutcliffe1:25:18

       Mm-hmm

    7. PAPeter Attia1:25:18

       ... in the field of, of, of autism therapy. Um, maybe describe what ABA is and explain perhaps why it's so polarizing.

    8. TSTrenna Sutcliffe1:25:27

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

    9. PAPeter Attia1:26:08

       What, what's an example?

    10. TSTrenna Sutcliffe1:26:09

        So an example would be, um- Oh, you put me on the spot, and I got to think of an example now. That's really good. Okay, let's think of something. Um, okay, it might be something to do with, um, greeting someone. Okay, appropriate greeting. An appropriate greeting would be integrating, um, verbal as well as eye contact, um, as well as maybe turning your body towards the person, so when you greet them, when you meet a new person.

    11. PAPeter Attia1:26:37

        Yep.

    12. TSTrenna Sutcliffe1:26:37

        And so for, so someone with significant autism, you know, that's, that's difficult, and they need to learn how to, you know, turn their body and make the eye contact and do the vocalization and how to integrate that.

    13. PAPeter Attia1:26:51

        Hmm.

    14. TSTrenna Sutcliffe1:26:51

        Um, so for that skill, you'd, you'd work on the different subsets. And so you might be first working on if you want to, like, greet someone and acknowledge them, you're first gonna look at them and make that joi- have that joint-

    15. PAPeter Attia1:27:04

        Yeah

    16. TSTrenna Sutcliffe1:27:04

        ... attention. So, um, you're gonna teach a child how to, um, how to make eye contact. So in the old fashion... So I'm gonna talk about, like, initially we called some- we, we did ABA with something called discrete trial. That's why it's controversial. Discrete trial, uh, which is still used today and still can be very helpful when it's combined with more naturalistic forms of ABA. Um, discrete trial would be about, like, teaching a child to make eye contact, and they get a reinforcer every time. So make eye contact, get a reinforcer, positive reinforcer.

    17. PAPeter Attia1:27:39

        Right.

    18. TSTrenna Sutcliffe1:27:39

        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, the eye contact and then the, the greeting and the, you know, the vocalization, turning your body. You would add all that together to come up with this larger thing of, like, how do you approach someone, okay? 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, it's not, you know, it's not based on relationships.

    19. PAPeter Attia1:28:09

        Hmm.

    20. TSTrenna Sutcliffe1:28:09

        So over the years, there are have been more naturalistic ABA, um, you know, 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.

    21. PAPeter Attia1:28:27

        Mm-hmm.

    22. TSTrenna Sutcliffe1:28:27

        Um, natural environment. Um, also trying to understand the child's natural motivators. So for example, um, 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, make eye contact. Here's your reinforcer. Make eye contact."

    23. PAPeter Attia1:28:47

        Right.

    24. TSTrenna Sutcliffe1:28:47

        "Here's your reinforcer," now we're at a park. This child wants to be pushed on the swing. Well, we're gonna 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. Um, and so those are more naturalistic forms. One of the most naturalistic forms is something called pivotal response treatment, PRT, um, which is actually training the parents in these skills 'cause that's really what it's about. It's like, um, it's not about whether this child can make eye contact with, you know, therapist A at the table.

    25. PAPeter Attia1:29:31

        Right.

    26. TSTrenna Sutcliffe1:29:31

        It's about does this eye c- 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, you know, the coffee shop, at w- you know, on the playground. The parents, so that is the most naturalistic form, teaching the parents. This comes back to parents, the, how powerful it is if you tr- teach parents. But parents work with the child in a natural setting with natural motivators.

    27. PAPeter Attia1:30:04

        Are there limitations to treatment in, you know, families with single parents?

    28. TSTrenna Sutcliffe1:30:09

        Yes. Yeah. You know, tr- well, well, well, when you, when you said that, I'm, I'm t- thinking, like, it's just a single parent. The time-

    29. PAPeter Attia1:30:20

        Yeah

    30. TSTrenna Sutcliffe1:30:20

        ... it's time and resources and driving to therapies. Um, again, it depends on how significantly impaired your child is and how many therapies they need.
13. 1:36:21 – 1:43:51

    Tips for parents trying to find & evaluate care for children with autism, ADHD, or anxiety

    1. PAPeter Attia1:36:21

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

    2. TSTrenna Sutcliffe1:36:56

       So what my advice would be with, for them would be, um, so start with your pediatrician. You start with your pediatrician, but you need to find, um... So, and your, your hope is with the pediatrician that they are able to connect you to resources and the network, um, because you really need to find a team. Um, it's, it's finding a team, th- and, and you also need-

    3. PAPeter Attia1:37:22

       How likely is that? I mean-

    4. TSTrenna Sutcliffe1:37:25

       It's hard.

    5. PAPeter Attia1:37:26

       Yeah, if you don't-

    6. TSTrenna Sutcliffe1:37:26

       It's hard

    7. PAPeter Attia1:37:26

       ... if you don't live in Boston-

    8. TSTrenna Sutcliffe1:37:29

       You don't

    9. PAPeter Attia1:37:29

       ... or, I don't know, San Francisco or the-

    10. TSTrenna Sutcliffe1:37:32

        I know

    11. PAPeter Attia1:37:32

        ... you know, or major cities, uh, I'm guessing that this multidisciplinary approach does not exist.

    12. TSTrenna Sutcliffe1:37:38

        No. And not, it's, it's not, uh, it's not easy to find.

    13. PAPeter Attia1:37:43

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

    14. TSTrenna Sutcliffe1:37:46

        Yeah, you try to create your team. But the thing is, I talk to families all the time. This is so s- it's, it is so stressful for a parent who's in a situation like this 'cause, um, they, they don't know th- anything about this. This, they weren't educa- they could be highly educated. And then we're talking about families who actually, if you, if you speak a different language and don't have higher education, h- this is a disaster. But even for families who are well-educated, like, you know, trying to understand and quarterback this. Basically, you need a quarterback to help you decide, like, is this ABA, you know, h- helpful or not? Is this, should I be, should I be focused on speech and language therapy or ABA therapy right now? Um, what, uh, what should I be advocating for at my, at my IEP meetings? Um- You, you really need someone to, to help you with that roadmap. So we need to help families more with that. It is, um, I think of myself as a Sherpa sometimes, guiding people along this journey.

    15. PAPeter Attia1:38:51

        Yeah.

    16. TSTrenna Sutcliffe1:38:52

        And it's, it's the roadmap of like, you know, at every, every year we pivot and turn. Like, "Okay, where, 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, it's, yeah, this is... It's hard to find, and so if you can't find it, you're looking for somebody, whether it's a ther- It may not be a doctor. It might end up being a really good, you know, ABA therapist-

    17. PAPeter Attia1:39:20

        Mm

    18. TSTrenna Sutcliffe1:39:20

        ... or a psychologist in your community who can help connect you. Um, there are state programs. Um-

    19. PAPeter Attia1:39:27

        What, what is a, what is a parent asking when they meet a provider to figure out, is this gonna be a good fit? I mean, obviously one option is just ask nothing and wait and see how it pans out.

    20. TSTrenna Sutcliffe1:39:39

        Yeah.

    21. PAPeter Attia1:39:39

        And in six months ask yourself the question, "Hey, is my, is my kid doing better today than they were six months ago?" But, but if you, if you as a parent had the chance to meet several providers, so the, "Hey, look, I happen to be lucky-"

    22. TSTrenna Sutcliffe1:39:51

        Yeah

    23. PAPeter Attia1:39:51

        ... "I live in a city. There's three ABA providers here. I'm gonna go and interact with each of them. What could I as a parent do to understand where should I go first? Which, which is, which of these three should I pick?"

    24. TSTrenna Sutcliffe1:40:04

        Yeah.

    25. PAPeter Attia1:40:05

        What are the clues that tell me this person is gonna have a higher probability of success?

    26. TSTrenna Sutcliffe1:40:10

        Yeah. So one thing is that you make sure that they have the philosophy that, um, one size does not fit all. So that is key, is that, um, this person needs to understand personalized care and that they don't just give the same, um, treatment recommendation, same thing to every single child. Um, it's not black and white, so you need to make sure that that provider is, um, flexible in their thinking and their treatment approach so that they can provide individualized care is one. Two would be, um, 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 you know, they're open to the idea of collaboration meetings with the child's speech therapist or teacher. So someone in, who is open to it but will also be proactive in arranging collaboration meetings maybe once a season. Um, three would be, um, I think s- someone who has skills in, um, parent-- I mentioned the parent training piece.

    27. PAPeter Attia1:41:42

        Mm.

    28. TSTrenna Sutcliffe1:41:42

        I think that's a really important piece. It's not just parent education, it actually is parent training, um, because I've seen that really, um, make a difference.

    29. PAPeter Attia1:41:55

        I think that's a great list. Um, um, I think, you know, again, I'm, I'm thinking about this through the lens of how do you scale kind of what you're doing, and-

    30. TSTrenna Sutcliffe1:42:04

        Yeah
14. 1:43:51 – 1:56:28

    Tailored treatments for ADHD: balancing stimulant medications with behavioral training

    1. PAPeter Attia1:43:51

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

    2. TSTrenna Sutcliffe1:44:03

       Before I answer that, I'm just gonna emphasize, so kids who come to my clinic with ADHD, um, come, often come to me, not always, but often come to me because it was a little bit more complicated, um, than straightforward-

    3. PAPeter Attia1:44:18

       Right. There's a selection bias-

    4. TSTrenna Sutcliffe1:44:19

       Yes

    5. PAPeter Attia1:44:19

       ... into your clinic. If this were straightforward, they wouldn't be coming to you.

    6. TSTrenna Sutcliffe1:44:23

       Yeah. So if it were straightforward, hopefully their pediatrician can manage it.

    7. PAPeter Attia1:44:26

       Okay. Yeah.

    8. TSTrenna Sutcliffe1:44:27

       S-

    9. PAPeter Attia1:44:27

       Makes sense.

    10. TSTrenna Sutcliffe1:44:27

        Yeah. So the percent of kids who are treated with medication, uh, depends on, like, the age of the child-

    11. PAPeter Attia1:44:35

        Mm

    12. TSTrenna Sutcliffe1:44:35

        ... and the severity of the ADHD. Um, so younger kids in my clinic, um, I will use behavioral interventions first.

    13. PAPeter Attia1:44:47

        Define young. What is that cutoff for you?

    14. TSTrenna Sutcliffe1:44:50

        So I see preschoolers-

    15. PAPeter Attia1:44:51

        Mm-hmm

    16. TSTrenna Sutcliffe1:44:52

        ... who come to me because they've been asked to leave multiple preschools-

    17. PAPeter Attia1:44:56

        Mm-hmm

    18. TSTrenna Sutcliffe1:44:57

        ... because they are hyperactive.

    19. PAPeter Attia1:44:59

        Yeah.

    20. TSTrenna Sutcliffe1:44:59

        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 gonna call this in the next couple years, let's start working towards helping your child build skills to regulate, you know, 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. Um, we may or may not need to add a medication. Um, the guideline for six 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. Um, 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.

    21. PAPeter Attia1:46:14

        Yeah.

    22. TSTrenna Sutcliffe1:46:14

        And 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."

    23. PAPeter Attia1:46:30

        I wanna dwell on this point, Trenna, because, um, I, 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, but there, there are gonna be people who-

    24. TSTrenna Sutcliffe1:46:41

        Yeah

    25. PAPeter Attia1:46:41

        ... understandably come at this and are really judgmental, and their narrative is gonna be the following: "These goddamn preschools trying to tell me a kid has, you know-

    26. TSTrenna Sutcliffe1:46:51

        Yeah

    27. PAPeter Attia1:46:51

        ... 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. You know, there's nothing wrong with a kid that's hyperactive. You just gotta give him more to do, blah, blah-

    28. TSTrenna Sutcliffe1:47:04

        Yeah

    29. PAPeter Attia1:47:04

        ... 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.

    30. TSTrenna Sutcliffe1:47:12

        Yeah, for sure.
15. 1:56:28 – 2:02:10

    The interplay between medication, behavioral therapy, & neuroplasticity in managing ADHD

    1. PAPeter Attia1:56:28

       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, in the, I hate to use the description this way, but I think you understand what I mean, in the drugged state-

    2. TSTrenna Sutcliffe1:56:47

       Yeah

    3. PAPeter Attia1:56:47

       ... 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?

    4. TSTrenna Sutcliffe1:56:59

       So, um- So I w- I want kids to be actually practicing skills when they're on the medication.

    5. PAPeter Attia1:57:07

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

    6. TSTrenna Sutcliffe1:57:13

       Yes. So, so let me say a couple things. So, um, so in theory, um, uh, when they're on the medication, they should be b- it's easier for them to practice paying attention-

    7. PAPeter Attia1:57:26

       Sure

    8. TSTrenna Sutcliffe1:57:26

       ... 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 s- a recommendation that every family should have, um, should be doing.

    9. PAPeter Attia1:57:38

       Training specifically for family, not just child.

    10. TSTrenna Sutcliffe1:57:42

        Tr- yes.

    11. PAPeter Attia1:57:43

        Okay.

    12. TSTrenna Sutcliffe1:57:43

        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. Uh, 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, um, when we practice something over and over and over again, not only we develop new, like, behavioral strategies, behavioral patterns, new habits, we actually positively impact the developing brain. That's neuroplasticity, which is one of my also, my, um, my passions is neuroplasticity. But we impact the brain through experience and our behaviors. Um, so when a child has ADHD, um, it is a wonderful time to practice new skills, and you actually impact neural networks.

    13. PAPeter Attia1:58:46

        So does that mean that you're telling parents or at least holding out a hope that, "Hey, you know, your kid is seven or eight years old. We're gonna put them on Ritalin. Um, this might not be a lifetime thing"? Is there-- do you have-- do you give them that hope, or do you not commit to anything one way or the other?

    14. TSTrenna Sutcliffe1:59:05

        I don't commit.

    15. PAPeter Attia1:59:05

        'Cause I, I get asked that question all the time-

    16. TSTrenna Sutcliffe1:59:07

        Yeah

    17. PAPeter Attia1:59:07

        ... for the types of medications I put patients on.

    18. TSTrenna Sutcliffe1:59:10

        Yeah.

    19. PAPeter Attia1:59:10

        Right?

    20. TSTrenna Sutcliffe1:59:10

        Yeah.

    21. PAPeter Attia1:59:10

        If I put patients on a lipid-lowering medication-

    22. TSTrenna Sutcliffe1:59:13

        Yeah

    23. PAPeter Attia1:59:13

        ... 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 gonna be on this for life?

    24. TSTrenna Sutcliffe1:59:21

        Yeah. So what I tell families, so I have no crystal ball.

    25. PAPeter Attia1:59:25

        Yep.

    26. TSTrenna Sutcliffe1:59:25

        I can't commit. But I do have many, many patients who do eventually come off medication. Some of them, um, 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.

    27. PAPeter Attia1:59:40

        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-twenties 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, to overcome the, the genetic component of this, or is that not necessarily correlated?

    28. TSTrenna Sutcliffe2:00:08

        No, I see a lot of kids who do, who do, um, find ways, strategies to compensate-

    29. PAPeter Attia2:00:15

        Mm-hmm

    30. TSTrenna Sutcliffe2:00:15

        ... um, and who do, you know, no longer need their medication as, uh, teenagers or young adults. I have a lot of kids who are like that. Um, but I think it's really important that they start early developing strategies and new behaviors. Um, I think that is really important in strengthening those neural networks.
16. 2:02:10 – 2:04:19

    Using medication to treat anxiety & other symptoms in kids with autism without ADHD

    1. PAPeter Attia2:02:10

       Are there any medications that typically show up in kids with, um, autism but without, um, ADHD? So let's just say-

    2. TSTrenna Sutcliffe2:02:21

       Yeah

    3. PAPeter Attia2:02:21

       ... kids with autism plus or minus anxiety, what is the role of pharmacotherapy?

    4. TSTrenna Sutcliffe2:02:25

       Yeah. So with au- there's no medication that treats the core symptoms of autism. So auti- 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, um, n- for the symptoms n-no matter the label. So whether or not the child with autism has ADHD or not-

    5. PAPeter Attia2:02:55

       Mm-hmm

    6. TSTrenna Sutcliffe2:02:56

       ... we still may use an ADHD medicine-

    7. PAPeter Attia2:02:57

       Yep

    8. TSTrenna Sutcliffe2:02:58

       ... if they're hyperactive or impulsive, we still may use it whether or not the label's there.

    9. PAPeter Attia2:03:03

       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-

    10. TSTrenna Sutcliffe2:03:10

        Yeah

    11. PAPeter Attia2:03:10

        ... and it's really just a function of the symptom.

    12. TSTrenna Sutcliffe2:03:13

        Correct. Correct. So the target symptoms we usually treat are the, um, it is the attention hyperactivity impulsivity, where we'll be using the stimulants, or the, um, challenges with emotional regulation, where we'll use a non-stimulant. Um, we may use an anxiety medicine, um, so a selective serotonin reuptake inhibitor, SSRIs, such as Prozac or Zoloft. We may use that, um, 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-

    13. PAPeter Attia2:03:53

        Mm-hmm

    14. TSTrenna Sutcliffe2:03:53

        ... so we'll use the SSRIs there. Um, and then kids who have really, um, aggressive behaviors, um, and may injure themselves, then we are talking about atypical antipsychotics, which I, I'll just share with you, I, I don't use a lot of those myself. I, um, I... At that point, if, if the child is having those, uh, difficulties, I often am working with a psychiatrist.

17. 2:04:19 – 2:06:52

    FAQs about medicating children with ADHD: benefits, side effects, dosage

    1. PAPeter Attia2:04:19

       Again, I think it's just got to be so hard for parents to potentially stomach-

    2. TSTrenna Sutcliffe2:04:24

       Yeah

    3. PAPeter Attia2:04:24

       ... putting children on psychiatric medication. But, um, 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."

    4. TSTrenna Sutcliffe2:04:37

       Yeah.

    5. PAPeter Attia2:04:37

       Which I, 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?

    6. TSTrenna Sutcliffe2:04:50

       Well, with the stimulants, it can be pretty quick.

    7. PAPeter Attia2:04:53

       Mm.

    8. TSTrenna Sutcliffe2:04:53

       They're like, um, "We're glad we did this, and this made-- it's making a big difference," 'cause the, the impact of stimulants is right away. You see the benefits right away.

    9. PAPeter Attia2:05:03

       What do the kids say? Let's assume a child is-

    10. TSTrenna Sutcliffe2:05:07

        Yeah

    11. PAPeter Attia2:05:07

        ... old enough.

    12. TSTrenna Sutcliffe2:05:07

        Yeah.

    13. PAPeter Attia2:05:07

        So let's assume you're, you're working with a seven-year-old or a-

    14. TSTrenna Sutcliffe2:05:11

        Yeah

    15. PAPeter Attia2:05:11

        ... 12-year-old, um, who can articulate their feelings.

    16. TSTrenna Sutcliffe2:05:14

        Yeah.

    17. PAPeter Attia2:05:14

        Like, what do they come back and say to you?

    18. TSTrenna Sutcliffe2:05:17

        Yeah. They, um, they share with me that it helps them with their focus. They feel more successful at school, and they share side effects. I'll be honest-

    19. PAPeter Attia2:05:27

        What other side effects-

    20. TSTrenna Sutcliffe2:05:28

        ... there are side effects

    21. PAPeter Attia2:05:28

        ... what other side effects do they complain of besides appetite suppression?

    22. TSTrenna Sutcliffe2:05:31

        Yeah. So I will sometimes have high school students who tell me that they feel less social and funny, uh, when they're taking their ADHD medicine, um, so they're a little less impulsive or spontaneous. And, and so we talk about that. The, and, and I listen because this isn't-- it doesn't have to be black and white, all or nothing. Like, our goal isn't to make someone, um, 100% focused 100% of the time. This is... Theirs could be... It's like, okay, so, um, 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, the dose is wrong, or maybe we should change to a different medication. Your-- this one particular medication may not, you know, 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. Um, again, it's like, it's just weighing pros and cons.

18. 2:06:52 – 2:09:26

    The “superpowers” associated with level 1 autism

    1. PAPeter Attia2:06:54

       You hear this, um, phrase from time to time which is that, you know, kids with autism have, have superpowers.

    2. TSTrenna Sutcliffe2:07:01

       Yeah.

    3. PAPeter Attia2:07:01

       Um, and, and sometimes we, you know, we might think of, you know, an example like, okay, well, Dustin Hoffman's character in Rain Man.

    4. TSTrenna Sutcliffe2:07:07

       Yeah.

    5. PAPeter Attia2:07:07

       I mean, obviously highly, highly impaired for most of life but clearly had a superpower, right? He could count cards [laughs] -

    6. TSTrenna Sutcliffe2:07:15

       Yeah

    7. PAPeter Attia2:07:15

       ... and toothpicks. Um, so obviously that's kind of the Hollywood version of that. But, but d- is there truth to this idea that, that, you know, kids with autism have, have superpowers, or is this something that you would put more brackets around and say, "Well, you know, sometimes those kids who are in class three where they're really impaired, you know, m- maybe there's something there, but it's, it's a lot harder to see than the kids in class one," for example?

    8. TSTrenna Sutcliffe2:07:41

       It is. So there is a difference, class three versus class one, for sure. Um, it's harder to see.

    9. PAPeter Attia2:07:47

       Yeah.

    10. TSTrenna Sutcliffe2:07:47

        It's harder to see in class three. Um, class one, a lot of superpowers.

    11. PAPeter Attia2:07:51

        Hmm.

    12. TSTrenna Sutcliffe2:07:51

        Um, memory, uh, could be one of them. Um, attention to detail. Um, really good with remembering rules and following, um, you know, routines or a set, set, you know, order of operations. Um, there's a lot of strengths with, with the kids in class one.

    13. PAPeter Attia2:08:15

        There are a lot of famous people I won't name who have even talked about themselves-

    14. TSTrenna Sutcliffe2:08:19

        Yeah

    15. PAPeter Attia2:08:19

        ... as having mild forms of autism, Asperger's. Um, so you would almost think that, that, that, you know, it's predisposing them to some of their greatness in, in, in, in the fields that they're in, often very technical fields.

    16. TSTrenna Sutcliffe2:08:33

        Yeah.

    17. PAPeter Attia2:08:33

        Is that kinda consistent with what you see in the children?

    18. TSTrenna Sutcliffe2:08:37

        Yes, it is.

    19. PAPeter Attia2:08:37

        A, a more, a more of a predisposition towards engineering, technical fields?

    20. TSTrenna Sutcliffe2:08:41

        D- I do.

    21. PAPeter Attia2:08:41

        STEM in general?

    22. TSTrenna Sutcliffe2:08:42

        Yeah, definitely. So it's less of the... You know, with that profile, like I s- I called it a learning profile, a thinking profile.

    23. PAPeter Attia2:08:49

        Mm-hmm.

    24. TSTrenna Sutcliffe2:08:49

        And so things where you need, um, a little bit more inferring, bla- you know, little bit more... There's abstract inferring or the social piece m- it may not be their strength. But where you need to dive deep into some Details, um, persevere, stick with something, hyperfocus 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, you know, a career where they can actually dive in, they can dive deep and do really, really well.

    25. PAPeter Attia2:09:25

        What do you

19. 2:09:26 – 2:15:30

    The next steps to increase support for children with ASD, anxiety, & ADHD

    1. PAPeter Attia2:09:26

       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?

    2. TSTrenna Sutcliffe2:09:42

       I think that there's a lot of overlap. Um, I think people sometimes get stuck on the label and name. And, um, although there's so many positive things, we're talking about the diagnosis you need to get resources, uh, I think I c- concern that people get stuck on a name and don't actually see the person beneath that name. And so, um, I think that's my key thing, is that... 'Cause I have, sort of had so many experiences where families are like, "But they told me it's autism. It has to be autism. If you think otherwise, like, you know, what's wrong with the system?" And this is hard, 'cause in this field, it's, there's a lot of gray. And so I think that's what it's about. It's c- there's gray. It's a moving target. We've, we've changed the names and the definitions multiple times in the last couple decades. They probably are gonna 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, um, what kinds of gaps you wanna, like, fill, and what kinds of skills you wanna work on.

    3. PAPeter Attia2:11:10

       Trenna, this has been really, really fascinating. Um, I, I guess my only frustration in this discussion is the concern that there aren't enough people like you and your colleagues, um, out there to match what is very likely, uh, the psychological burden of these conditions across kids today. And I'm, and I'm only speaking to the United States, so I think if you were to think about this globally, I, I, I won't, I won't attempt to make a statement 'cause I simply don't understand what the prevalence is or what the, what the resources are. But, but I think we could probably say in the United States that there are far more children and families that are impacted by the triple-A 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 gonna be more people that are gonna wanna come to practice this in the way... Like, wh- where, where is the, uh, the long pole in the tent? Is it getting more people to simply go into these fields? Is it, uh, a better payer reimbursement structure to incentivize more people around a multidisciplinary approach? What is it gonna take in 10 years to close the gap between demand and supply?

    4. TSTrenna Sutcliffe2:12:26

       I think it's both those things you mentioned. Um, it is definitely training more people, and trying to think about, um, um, how to use, um, and recruit people who are, who are also gonna support, for example, the developmental behavioral pediatrician or the psychiatrist or the, or the psychologist. Like, um, for example, we need more DBPs, but we also need then, like, more, maybe more nurse practitioners or other, you know, allied profe- you know, professionals who could, can support the team. So it's, it's being creative-

    5. PAPeter Attia2:13:01

       Mm-hmm

    6. TSTrenna Sutcliffe2:13:02

       ... and innovative with how you create the teams and find enough people to, to be in the, on these teams. But then, um, how it's reimbursed and, um, and making sure there's access to these teams will be really important. I really believe in the bridge to, to education as well, which is not something that is-

    7. PAPeter Attia2:13:22

       Well, it's funny you say that-

    8. TSTrenna Sutcliffe2:13:23

       ... part of an insurance model

    9. PAPeter Attia2:13:24

       ... 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 healthcare when maybe this should be done through education?

    10. TSTrenna Sutcliffe2:13:39

        Yeah.

    11. PAPeter Attia2:13:39

        Now, again, i- if, if, if you had unlimited budget, right? So if y- look, one way or the other, this has gotta get paid for.

    12. TSTrenna Sutcliffe2:13:45

        Yeah.

    13. PAPeter Attia2:13:45

        So it's either gonna get paid through, through health insurance, or it's gonna get paid through via systems in education. Um, 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.

    14. TSTrenna Sutcliffe2:14:02

        Yeah.

    15. PAPeter Attia2:14:02

        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?

    16. TSTrenna Sutcliffe2:14:16

        Yeah. It's, it's tricky 'cause it's... I, I, I'm gonna go back to it, the bridge.

    17. PAPeter Attia2:14:20

        Yep.

    18. TSTrenna Sutcliffe2:14:20

        'Cause it is. It's like the insurance, um, you know, they'll say that parts of this intervention are educational-

    19. PAPeter Attia2:14:28

        Mm-hmm

    20. TSTrenna Sutcliffe2:14:28

        ... so they're not responsible for it. And then the educational people will say that, you know, "Well, this part is, this medical thing-"

    21. PAPeter Attia2:14:36

        This is medical. Yeah

    22. TSTrenna Sutcliffe2:14:36

        ... it's actually not interfering with the classroom. But to help that child, this is the, this, it's, 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 wanna move forward. And so it's a totally different system, but I really believe in bridging education, mental health, and medical if you wanna make an impact on child well-being and health.

    23. PAPeter Attia2:15:08

        Well, I am, I'm really hopeful that, that this message spreads and that-

    24. TSTrenna Sutcliffe2:15:12

        Yeah

    25. PAPeter Attia2:15:12

        ... we, we see more and more of this type of integrative approach, because it, it really makes sense. So thank you so much for your time, and appreciate you coming out here.

    26. TSTrenna Sutcliffe2:15:19

        Thank you, Peter. [upbeat music]

Episode duration: 2:15:30