The Peter Attia Drive
#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.
06 Jan 2025
Chapter 1: What is the main focus of this podcast episode?
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
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Trenna is a developmental behavioral pediatrician and the founder and medical director of the Sutcliffe Clinic in the Bay Area, which partners with patients and their families to evaluate and provide supportive care for children dealing with issues such as behavioral changes, developmental differences, and school struggles.
In my conversation with Trenna, we explore her journey into developmental and behavioral pediatrics. In fact, she was the first person to be practicing under this designation at Stanford when she arrived about 20 years ago.
This includes her background in genetics, pediatric neurology, and her current work in leading multidisciplinary teams around the care of children with autism, ADHD, and anxiety.
We spoke about the diagnostic processes for autism, ADHD, and anxiety, which he calls the three A's, discussing how these behavioral diagnoses are made based on clinical traits and the criteria depending on the age of a child. We focus on the overlap between the three A's and how comorbidities are common in children with each of these conditions.
Trenna emphasizes the importance of a personalized treatment plan to consider the whole child, including their environment at home and school. We talk about the changing diagnostic criteria for autism between the DSM-IV and the DSM-V, and what some of the drivers might be for the increase in the prevalence of autism today. This is a very hotly discussed topic.
Trenna provides a very thorough discussion of what the factors are that may be contributing to this. We discuss the various therapies, including applied behavioral analysis, or ABA for autism, behavioral interventions, and parental training for ADHD. We cover pharmacologic options, particularly for ADHD and anxiety, including the use of stimulants, non-stimulants, and SSRIs.
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Chapter 2: How do we diagnose anxiety, ADHD, and autism?
But again, I'll just tell you from my clinical experience, I rarely jump onto the diagnosis with a four or five-year-old because they're still a moving target. Although I may start interventions, behavioral interventions and parenting support, but there are a lot of four-year-olds who are pretty busy. So I generally wait closer to school age, although technically you can make it as young as four.
So that would be for most kids, when you say school, you don't mean preschool, you mean actual kindergarten, five to six?
Five to six, I think. A lot of people will wait till five or six to really see how that child is evolving, although technically you could make it younger. And then with anxiety, there's separation anxiety. There's something called selective mutism in young kids, in preschoolers. So anxiety, there's many different types of anxiety, but there's definitely anxiety conditions in preschoolers.
Let's talk a little bit more about that. I don't know much about anxiety, and I'm guessing most people listening have a sort of hand-waving sense of what it means, but you said separation anxiety is an example. Anyone who's been a parent can appreciate moments of that. 99% sure our puppy has separation anxiety. What are some of the other types of anxiety, and how do you look to spot those in kids?
So again, just to emphasize, anxiety is actually a normal emotion that we should all have. So it's all about whether it's created enough impairment. So in the anxiety bucket, there's multiple different types. So someone may have generalized anxiety where that's exactly it. It's generalized. It's seen in multiple places as pretty pervasive.
People can have specific phobias towards dogs or spiders or other things. I mentioned separation anxiety, so that is a condition. And again, yes, many toddlers have separation anxiety. That's very normal. It's about how severe and significant the anxiety is and how pervasive it is and whether it is impacting function.
So when it's impacting the ability for a child to go to childcare or preschool, then it's something we need to help. Other types of anxiety, there's something called selective mutism. Children who are able to speak very well and speak well at home or with familiar adults, but do not speak and are mute outside that familiar environment.
There's also obsessive compulsive disorder, where people have obsessive thoughts or compulsive behaviors. So there's many types of anxiety conditions out there, and children have these.
You've reiterated it twice now, which tells me how important it is. It really has to come down to this impairment thing.
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Chapter 3: What factors contribute to the rising prevalence of autism?
But on the backbone of those things, you can put little methyl groups, which is just a little carbon with three hydrogens. And that's called epigenetics. And by the way, we're all born with methylated groups all over our epigenome, back of the genome. Over life, no, that changes.
So we know that simply aging changes methylation, but we believe that there is differential methylation in individuals in response to all the things that you've talked about. And we know that methylation controls gene expression. In fact, methylation is probably the single most important thing that controls differential gene expression in different tissues.
So the question, the jugular question is, if you have a methylation pattern, can you pass that on to your fetus? And what you said a minute ago is even more remarkable, which is, would that child, when they develop, pass that methylation pattern on to their fetus? At that point, methylation epigenetics would start to become genetic, right? It starts to become a part of the germline.
So, I mean, this is an answerable question, by the way, in my book. When I think of things that we should know the answer to in a decade, I'm going to put this in the list of things that we should know the answer to just based on the fact that we will have enough longitudinal data, I think, to be able to get at this. I don't know if you're as optimistic as me.
I am. The key thing is that we do know the environment impacts the methylation and the epigenetics. So it's the idea of it crossing generations. It's the idea of the methylation in a germ cell is altered or changed because of some sort of environmental exposure in, again, that parent or grandparent.
And so in that sense, the child is now susceptible to two things. The germline that they inherit from both parents and as a fetus, the methylation impact that occurs. as a result of any of these other factors you've discussed. Who are the people that are studying this most closely? Is this in the purview of the geneticists? Is this in the purview of the epidemiologists?
Who are the people that are most working at this? Because again, as a general rule, I always think that it's very foolhardy to work on a problem, an epidemic, without understanding the causal nature of the epidemic. I use the example of heart therapy. Change the face of HIV forever. One of the greatest success stories of infectious disease, medicine.
But it was all predicated on understanding what the cause was. If you didn't understand that HIV was destroying CD4 cells, you didn't have a prayer of developing that therapy. And do you ever worry that what's to say this isn't going to get to be one in three kids in 30 years?
And are there enough people like you that are going to be able to help parents and help families and help children with that? I don't want to sound alarmist, but I worry when we have an epidemic potentially and we don't have a great sense of causality.
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Chapter 5: What is the significance of personalized treatment plans?
By the way, one of the reasons they actually went from the Asperger syndrome, PDD-NOS, autistic disorder, because that was actually quite controversial when they actually decided to put all three of those things under one umbrella called Autism Spectrum. was because clinicians did a really poor job of deciding- Which bucket you were in. Which bucket you were in.
So you would have a child, and one clinician would call it Asperger's syndrome, another person would call it autistic disorder, another person would call it PDD-NOS. So they decided, okay, rather than having these three names, let's put it all under autism spectrum. So then they put it under autism spectrum, but then they have level one, level two, level three.
But I would still say that clinicians still struggle sometimes where there is a little bit of overlap. It's not always clear.
Now, if you go back to DSM-IV, when, as you mentioned, physicians are struggling to know which of these buckets to put them into, as an outsider looking in, my first question is, does it matter in terms of treatment and resources? Does it matter more in terms of outcomes and support? There must be a reason why people cared about that.
In other words, if you had a child in the year 2000 who one clinician said, this kid has Asperger's syndrome and another person said, no, they're autistic. Was that going to make a material difference in the type of support that they got? And most importantly, the type of person they were going to turn into, like, were they going to reach their full potential interdifferential capacity?
So it did make a difference with respect to resources. Children with Asperger's syndrome frequently did not get support or support covered. You needed autistic disorder to get support.
And what about PDD-NOS?
Waste bucket? Yeah, people didn't know what to do with that. So if by putting everything under autism, then it's like, okay, if you have autism, you should receive services. It was a tool. The label's a tool to understand and get resources. Now we have level one, level two, level three now. Level one is it says requires support. Level two is requires substantial support.
Level three is require very substantial support. My concern is that, again, when a child is level one, they don't always get the support they need because they have so many strengths. So kids in level one, frequently they have good cognitive skills. They have a lot of language skills.
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Chapter 7: What challenges do families face in accessing care?
Waste bucket? Yeah, people didn't know what to do with that. So if by putting everything under autism, then it's like, okay, if you have autism, you should receive services. It was a tool. The label's a tool to understand and get resources. Now we have level one, level two, level three now. Level one is it says requires support. Level two is requires substantial support.
Level three is require very substantial support. My concern is that, again, when a child is level one, they don't always get the support they need because they have so many strengths. So kids in level one, frequently they have good cognitive skills. They have a lot of language skills.
They struggle with some social skills and they may have some difficulties with executive functioning and coping skills at times. But again, it's considered mild and a lot of those kids don't get support. And I think that's unfortunate because they also are the kids that respond to intervention so well. If they get a little coaching on how do you cope with distress? How do you cope with change?
How do you practice some social skills? Not that they have to change. We don't need to change everything about them, but giving them a little bit of support about how to, again, be adaptive in a community. Giving that support goes a long way with that group. But frequently they don't get the support because they're called level one.
Help me understand the natural history of those kids back in the 70s and 80s. Back in the 70s and 80s when you and I were kids, nobody thought anything of those kids, right? Certainly weren't going to get labeled with autism. They certainly weren't going to show up with in-school programs to help them with their social skills and with their communication skills.
As you pointed out, they're intellectually not impaired, so it's not like they're going to struggle in school. But there's clearly something that they're struggling with. Obviously, this hasn't been studied, but I'm very curious based on your experience and your judgment.
Are those people that just went on to pick careers where they didn't have to interact with people, but they could still do challenging cognitive work? What was the natural history of them? There are clearly a lot of them.
There are. There are a lot of them. And I think they found a path that made sense to them. They obviously learned what their strengths were, and their strengths may have been around memory, detail-oriented, following rules that are black and white. They may have had really wonderful cognitive skills in certain areas that were less around inferring and social skills and more concrete. And yeah,
We don't have studies to say this for sure, but my guess is they have lived happy, successful lives, a lot of them, some of them, doing things that they enjoy doing or are passionate about. They probably have found ways to not engage in large social settings, but there's a lot of careers out there that are a good match.
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