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

Trenna’s passion for developmental-behavioral pediatrics (DBP), and the process of diagnosing anxiety, ADHD, and autism [3:15]

• Trenna did her undergrad and master’s degree in genetics, then went on to medical school
• After medical school, she did a residency in pediatrics but ultimately wanted to do developmental-behavioral pediatrics
  • It was a good fit with her interested and passions
• She did a year in pediatric neurology and then a fellowship in developmental-behavioral pediatrics before moving to California
• Her interests today primarily revolve around behavioral therapy for 3 things that we’re going talk about: autism, ADHD, and anxiety 
• We’re coming at this through the lens of what Trenna does today
  • Which is running a really large, successful multidisciplinary clinic for children up to 18 years old

How are the diagnostic criteria defined, and how does a practicing clinician use the DSM-5 or maybe modify that in the way that they try to come up with a diagnosis?  

⇒ Anxiety, ADHD, and autism are all behavioral clinical diagnoses based on checklists of a number of traits and characteristics

• You need to be working with a physician trained in these conditions who has enough experience diagnosing these conditions 
• Essentially, that person needs to be an expert on what the clinical picture looks like because there’s no biomarkers for any of these conditions
  • That’s the key thing: there are no blood tests, no brain scans to say who has anxiety, who has ADHD, who has autism

Trenna explains to families all the time, “I have these clinical boxes and labels and diagnoses in my clinic, and these boxes and are manmade. We create these lists of criteria, but neurobiology in the brain is much more complex than these boxes.”

• The key thing is to have a clinician who collects lots of data on the child
  • Their traits at home, at school, in multiple environments 
  • Talking to parents, getting the history
  • Getting information from people other than parents: using rating forms or talking to teachers and therapists
  • Ideally, we get to see the child in their real-life environments
    • Maybe even observing them in a real-life place like school 
  • And then doing assessment in the clinic to collect information about them 
• With that, the clinician decides whether or not they meet diagnostic criteria
  • A list of traits or characteristics described in a book called the DSM

⇒ One of the key things is about whether or not those traits are creating impairment, and that’s a key criteria for any of these diagnoses 

For example, anxiety 

• We all have feelings of anxiety
• Anxiety is actually a very appropriate normal feeling that we should all have, but it’s all about how much impairment is it creating, how does it impact function, and impact someone doing their job
• For a child, their job is to learn and go to school, make friends, practice communicating and interacting with other peers, and be a positive contributor in their community (which is school)
• So it’s about how these traits impact their function in that job

What would you say is the youngest age that each of those could be diagnosed? 

• For autism, we can confidently make that diagnosis as young as 18 months of age
  • Although the typical age for diagnosis is 3 or 4 [years old]
• In the last 20 years, there’s been 1 or 2 cases where Trenna has made it at 15 months of age because it was very significant and obvious
  • Most often, at that young age, we do wait a few more months to watch how the child develops because kids are moving target
• With autism, it can be 18 months, 2 years of age
  • Although half of the cases of autism are diagnosed over 6 
• With ADHD, you can make a diagnosis as young as 4 years of age
• But from Trenna’s clinical experience, she rarely jumps into the diagnosis with 4- or 5-year-olds because they’re still a moving target
• She may start behavioral interventions and parenting support but generally waits closer to school age 

Peter asks, “When you say school, you don’t mean preschool. You mean actual kindergarten, 5 to 6?”

• Yes, a lot of people will wait till 5 or 6 to really see how that child is evolving, although technically you could make it younger
• With anxiety, there’s many different types of anxiety
  • There’s separation anxiety 
  • There’s something called selective mutism in young kids in preschoolers
• There’s definitely anxiety conditions in preschoolers

Understanding anxiety and ADHD: assessing impairment and self-esteem and identifying anxiety and emotional well-being in young patients [9:45]

• You said separation anxiety is an example, and anyone who’s been a parent can appreciate moments of that

What are some of the other types of anxiety, and how do you look to spot those in kids? 

“Anxiety is actually a normal emotion that we should all have. So it’s all about whether it’s creating enough impairment.”‒ Trenna Sutcliffe

• Someone may have generalized anxiety: it’s seen in multiple places as pretty pervasive
• People can have specific phobias towards dogs or spiders or other things
• There’s separation anxiety
  • Many toddlers have separation anxiety and that’s very normal
  • It’s about how severe and significant the anxiety is, how pervasive it is, and whether it is impacting function
  • When it’s impacting the ability for a child to go to childcare or preschool, then it’s something we need to help
• There’s something called selective mutism
  • Children who are able to speak very well and speak well at home or with familiar adults but do not speak and are mute outside of that familiar environment
• There’s also obsessive-compulsive disorder, where people have obsessive thoughts or compulsive behaviors

Peter notices, “You’ve reiterated it twice now, which tells me how important it is. It really has to come down to this impairment thing.”

• He points out that all of us could probably read through the DSM-5 and place ourselves in each of these diagnostic buckets
• The truth of it is to ask, “Which is maladaptive, which is mostly giving me the negative response that is impacting relationships or work or these other things?”
  • Peter likes that framework for kids because you may think that your kid has ADHD but they’re doing well in school, enjoy playing sports, and have friends

How would you help a parent navigate that if they think their son, daughter has ADHD 

What are the impairment-style questions you would be asking to paint the contours of this condition, even if you acknowledge that that kid’s got a lot of energy? 

• Those are great questions because it is definitely a spectrum (there’s a bell curve)
  • We’re all on a bell curve
• When does it become leaving the average range (the typical profile) and over into what we call a disorder?

Trenna adds the caveat, “I don’t like to use the word disorder for these conditions either because I think they’re just learning differences and thinking differences as well.”

Questions around impairment, the #1 thing she talks about with families is self-esteem 

• How is it impacting that child’s self-concept, how they see themselves? 
• How is it impacting their relationships with peers? That’s another key one
  • Does it impact social interactions? 
  • Does it impact how they connect with peers? 
  • Does it impact the feedback they’re getting from peers? 
• How does it impact their ability to learn and access learning opportunities at school or on the playground?
  • Are these traits impacting their ability to fully engage in learning, be successful, show their potential? 

Trenna emphasizes, “The self-esteem thing is very important to me.”

These are all biologic conditions: there’s neurochemicals, there’s genetics involved 

• And for a child to have a biologic condition and be in class and then feel bad because they are worried they’re not doing well enough, and they’re getting a lot of negative feedback from teachers and peers, not because those people are trying to be mean or negative, but they have to constantly remind that child because that child is forgetting things, losing things, forgot to put their name on the piece of paper, completely off task
• It’s not sustaining attention in a conversation
• It’s actually avoiding tasks that require a lot of sustained attention

There’s a lot of these traits where it’s impacting the child’s ability to be successful day to day at school 

How do you assess self-esteem?

{end of show notes preview}