#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.
Dr. Trenna Sutcliffe, a developmental behavioral pediatrician, discusses diagnosing and treating autism, ADHD, and anxiety ("the three A's") in children. She emphasizes personalized, multidisciplinary care, the impact of changing diagnostic criteria, and bridging healthcare with education for holistic support.
Deep Dive Analysis
18 Topic Outline
Trenna Sutcliffe's Background and Expertise
Diagnostic Criteria for Anxiety, ADHD, and Autism
Assessing Impairment and Self-Esteem in Children
The Evolving Diagnosis of Autism Spectrum Disorder (ASD)
Drivers of Increased Autism Prevalence: Genetics and Environment
Epigenetics and Multigenerational Environmental Impact
Challenges with Autism Classification and Support for Level 1 ASD
The Broadening Autism Spectrum: Benefits, Risks, and Future Frameworks
Overlap and Comorbidities of ASD, ADHD, and Anxiety
Understanding Oppositional Defiant Disorder and Behavioral Function
Defining Developmental-Behavioral Pediatrics (DBP) and Trenna's Journey
Evolution and Controversies of Applied Behavioral Analysis (ABA) Therapy
Advice for Parents Navigating Care for Children with Neurodevelopmental Conditions
Tailored Treatments for ADHD: Stimulants and Behavioral Training
Pharmacotherapy for Anxiety and Other Symptoms in Autism
Patient Experience and Side Effects of ADHD Medication
The 'Superpowers' Associated with Level 1 Autism
Future of Integrated Care for Children with ASD, Anxiety, and ADHD
6 Key Concepts
Biopsychosocial Specialty
This framework considers the interplay of biological factors (genetics, brain, medication), psychological factors (mental health, well-being), and social factors (family dynamics, parenting, school, community) to support child development and behavior. It emphasizes that human well-being is not isolated but influenced by these interconnected domains.
Impairment in Diagnosis
For behavioral diagnoses like anxiety, ADHD, and autism, the key criterion is whether the traits are creating significant impairment in a child's function. This means assessing how the condition impacts their ability to learn, go to school, make friends, communicate, and contribute positively in their community, rather than just the presence of symptoms.
Autism Spectrum Disorder (ASD)
A broad umbrella term for a range of neurodevelopmental conditions characterized by differences in social communication skills and repetitive behaviors or restricted interests. The spectrum ranges from non-verbal individuals with significant communication challenges to those with strong cognitive and language skills but subtle social difficulties.
Epigenetics
Refers to changes in gene expression that do not involve alterations to the underlying DNA sequence, but rather 'tags' on the DNA or changes to proteins called histones. These modifications can be influenced by environmental factors and can potentially be inherited across generations, impacting susceptibility to conditions like autism.
Applied Behavioral Analysis (ABA)
A behavioral intervention traditionally used for children with autism, which involves breaking down complex skills into smaller, manageable steps and using positive reinforcement to teach them. While traditional ABA used discrete trial training, modern approaches emphasize more naturalistic settings and parent training (like Pivotal Response Treatment) to generalize skills.
Neuroplasticity
The brain's ability to change and adapt in response to experience, learning, and behavior. In the context of ADHD, practicing new skills and developing new behavioral strategies, especially with the aid of medication, can positively impact neural networks and strengthen areas of the brain responsible for executive functioning.
8 Questions Answered
Autism can be confidently diagnosed as young as 18 months, though half of cases are diagnosed over six years old. ADHD can technically be diagnosed at four years old, but clinicians often wait until closer to school age (five or six). Anxiety conditions, such as separation anxiety or selective mutism, can be diagnosed in preschoolers.
These are behavioral clinical diagnoses based on checklists of traits and characteristics, as there are no biomarkers like blood tests or brain scans. A clinician assesses the child's traits across multiple environments (home, school), collects data from parents and teachers, and observes the child to determine if they meet DSM criteria and if these traits cause significant impairment.
The diagnosis requires observed differences in two main areas: social communication skills (including social reciprocity, nonverbal communication, and understanding relationships) and repetitive behaviors or restricted interests. A patient must show differences in all three specific areas of social communication to receive the diagnosis.
While changes in diagnostic criteria (DSM-5 in 2013), increased awareness, and more clinicians making diagnoses contribute, experts believe these factors alone don't fully explain the drastic rise. Research is exploring the impact of environmental factors like pollution, maternal infection, stress, parental age, and epigenetics, suggesting a 'multiple-hit' model involving gene-environment interactions.
About half of children with autism also receive an ADHD diagnosis, and around 40% of children with autism also have anxiety. ADHD frequently co-occurs with anxiety, other mood challenges, learning differences, or oppositional behaviors, indicating significant comorbidity across these conditions due to shared underlying neurological pathways.
Medication, primarily stimulants (methylphenidate and amphetamine-based drugs) and non-stimulants, increases dopamine and norepinephrine in brain synapses to improve communication between brain cells in areas responsible for executive functioning. It is often used in conjunction with behavioral parent training, especially for children aged six and older, to help manage symptoms and improve skill development.
While there's no guarantee, many patients do eventually come off medication as teenagers or young adults. This is often due to developing compensatory strategies and new behaviors, which strengthen neural networks through neuroplasticity. Starting early with skill development and behavioral interventions is crucial for this potential outcome.
There is no medication that treats the core symptoms of autism itself; therapy addresses those. However, medication is used to treat target behaviors and associated symptoms in children with autism, regardless of an ADHD diagnosis. This includes using ADHD medicines for hyperactivity or impulsivity, SSRIs for anxiety or rigidity, and sometimes atypical antipsychotics for severe aggression.
20 Actionable Insights
1. Prioritize Whole-Child Personalized Care
Focus on understanding the unique profile of each child, including their strengths and challenges, rather than just their diagnostic label, to create effective and personalized treatment plans.
2. Understand Behavior’s Underlying ‘Why’
When observing oppositional or challenging behaviors in children, seek to understand the underlying reasons (e.g., anxiety, impulsivity, social difficulties, sensory overload) as this ‘why’ is crucial for developing effective interventions, rather than simply labeling the behavior.
3. Assess Impairment for Diagnosis
When considering a diagnosis for anxiety, ADHD, or autism, focus on whether the child’s traits are creating significant impairment in their function, such as their ability to learn, make friends, or contribute positively in school and community settings.
4. Engage in Behavioral Parent Training
Participate in behavioral parent training, especially for ADHD in children under six, as parents can be incredibly powerful in modifying a child’s behavior and helping them develop new skills and habits.
5. Seek Integrated Multidisciplinary Teams
Look for healthcare providers and clinics that offer an integrated, multidisciplinary team approach, including collaboration with teachers and therapists, to ensure all professionals are working from the same understanding of the child’s needs.
6. Select Flexible, Collaborative Providers
When choosing a provider, ensure they embrace a ‘one size does not fit all’ philosophy, are proactive in arranging collaboration meetings with other professionals (e.g., speech therapists, teachers), and have strong skills in parent training.
7. Utilize Applied Behavioral Analysis (ABA)
Consider ABA as a behavioral intervention, particularly for children with autism, focusing on naturalistic forms like Pivotal Response Treatment (PRT) that train parents to apply skills in the child’s everyday environment with natural motivators.
8. Evaluate ABA Therapist Quality
When selecting an ABA therapist, prioritize those who are well-trained, well-supervised, and demonstrate a nuanced understanding of autism and the individual child’s profile, rather than just following a generic ‘recipe’.
9. Consider Medication for ADHD (Ages 6+)
For children aged six and older with ADHD, consider medication (stimulants or non-stimulants) alongside behavioral parent training, as research shows it can significantly help with focus, impulse control, and overall success, with many parents wishing they started sooner.
10. Manage ADHD Medication Side Effects
If a child experiences side effects from ADHD medication (e.g., decreased appetite, sleep issues, feeling less social), communicate with the doctor to adjust the dose, timing, or switch to a different medication or brand to optimize benefits and minimize negatives.
11. Leverage Medication for Skill Practice
Understand that ADHD medication can make it easier for children to practice and develop new skills, such as attention and impulse control, which in turn strengthens neural networks and can lead to lasting behavioral changes through neuroplasticity.
12. Use Non-Stimulants for Emotional Regulation
For children with ADHD, especially those with emotional dysregulation or impulsive emotions, consider non-stimulant medications (e.g., Strattera, guanfacine, clonidine), which can be used alone or in combination with stimulants.
13. Medicate Autism Symptoms, Not Core Condition
For children with autism, medication does not treat the core symptoms but can be used to address specific target behaviors and associated symptoms like hyperactivity, impulsivity, emotional dysregulation, anxiety, rigidity, or aggression.
14. Bridge Healthcare and Education Systems
Advocate for and seek collaboration between healthcare providers and educational institutions (e.g., school observations, IEP meetings) to create a holistic and integrated approach that supports a child’s development and well-being.
15. Recognize Neurodiversity, Avoid Labels
Be flexible in thinking about diagnoses, understanding that definitions change and that ’neurodiversity’ means everyone is different; focus on understanding the individual person rather than getting fixated on a label.
16. Consider Adult Assessment for Validation
If you are an adult who recognizes your own childhood traits in your child’s diagnosis, consider seeking an assessment for yourself, as this information can be empowering for self-understanding and improving relationships and work performance.
17. Start Early with Autism Diagnosis
If concerns arise, seek an autism diagnosis as early as 18 months (though typically 3-4 years), as early intervention can significantly impact a child’s development.
18. Start Early with ADHD Diagnosis
For ADHD, while diagnosis is technically possible at four years, consider waiting closer to school age (five to six) to observe how the child evolves before making a definitive diagnosis, though behavioral interventions can start earlier.
19. Start Early with Anxiety Diagnosis
Be aware that anxiety conditions, such as separation anxiety or selective mutism, can be diagnosed in preschoolers, and early intervention can help when it impacts a child’s ability to function.
20. Use Third-Person for Child Self-Esteem
When assessing self-esteem in primary elementary school-aged children, use third-person scenarios (e.g., ‘Why might another child feel uncomfortable?’) to help them relate and articulate their own feelings and experiences.
6 Key Quotes
You've met one child with autism, you've met one child with autism.
Trenna Sutcliffe
The label is only one piece of it. If someone tells me their child has autism, I actually really don't know much about their child.
Trenna Sutcliffe
The self-esteem thing is very important to me, though. So for a child who has 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.
Trenna Sutcliffe
I think information is power. I think it's good for them to be thinking about it, whether or not they go on to actually get assessed.
Trenna Sutcliffe
The point is, is like when I see a child with oppositional behavior and a family says, oh, well, someone told us it was ODD. I'm like, now what? I want to come actually right back to that.
Trenna Sutcliffe
I think that there's a lot of overlap. I think people sometimes get stuck on the label and name. And although there's so many positive things, we're talking about the diagnosis you need to get resources, I think I'm concerned that people get stuck on a name and don't actually see the person beneath that name.
Trenna Sutcliffe
2 Protocols
First-Line Treatment for ADHD (Under 6 years old)
Trenna Sutcliffe- Implement behavioral parent training as the primary intervention.
- Consider adding medication if behavioral interventions are insufficient, though typically behavioral approaches are tried first.
First-Line Treatment for ADHD (6 years and older)
Trenna Sutcliffe- Initiate medication (stimulants or non-stimulants) to manage core symptoms.
- Combine medication with behavioral parent training to develop skills and strategies.