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

Impairment is a key criterion for all these diagnoses. It refers to how much the traits or characteristics impact a child's function in daily life, such as their ability to learn, make friends, communicate, or contribute positively in school.

The diagnosis of ASD, as defined by the DSM-5 since 2013, requires differences in two main areas: social communication skills (social reciprocity, non-verbal communication, understanding relationships) and restricted interests/repetitive behaviors. The presence of intellectual disability or language impairment is also noted.

The increase is complex. While changes in diagnostic criteria (such as the introduction of DSM-5 in 2013 combining various previous diagnoses under ASD) and increased awareness contribute, experts believe these factors don't fully explain the drastic changes. Environmental factors like maternal infection, pollution, prenatal stress, and parental age, interacting with genetics and epigenetics, are also being researched.

The heritability of autism is quite high, estimated between 70% to 98%, potentially higher than any other condition in the DSM. However, it is not due to a single gene but rather multiple genetic changes, forming a unique 'fingerprint' for each individual with autism.

Before DSM-5 (2013), diagnoses included Asperger Syndrome, PDD-NOS, and autistic disorder. Clinicians often struggled to categorize children accurately. DSM-5 combined these under the umbrella term Autism Spectrum Disorder (ASD), with severity levels (Level 1, 2, 3) to better streamline diagnosis and resource allocation.

There is significant overlap. About half of children with autism also have an ADHD diagnosis, and about 40% also experience anxiety. This makes sense given the brain regions involved, such as the prefrontal lobes for executive function and the amygdala for anxiety. Many children may have all three conditions.

While ODD is a diagnostic label, clinicians like Dr. Kang focus on understanding the 'why' behind oppositional behaviors rather than just the label. These behaviors can stem from anxiety, impulsivity (untreated ADHD), social skill deficits, or sensory overload, each requiring a different therapeutic approach.

Dr. Kang emphasizes personalized, integrative care, focusing on the child's unique profile, strengths, and challenges rather than just the diagnosis. Her clinic uses a 'biopsychosocial' approach, considering biological, psychological (mental health), and social (family, school, community) factors, and involves multi-disciplinary teams and parent training.

ABA is a behavioral intervention used for autism, breaking skills into smaller, repeatable steps. Traditionally, it was very direct and adult-led, leading to controversy over its repetitive nature and lack of relational basis. Newer, more naturalistic forms of ABA, like Pivotal Response Treatment (PRT) which involves parent training in natural settings, are now more common.

Stimulants like methylphenidate (Ritalin, Focalin, Concerta) and amphetamines (Adderall, Vyvanse, Dexedrine) are first-line treatments, working by increasing dopamine and norepinephrine. Common side effects include decreased appetite and potential sleep onset issues. Non-stimulants like Strattera, Guanfacine, and Clonidine are also used, often combined with stimulants, for conditions like emotional dysregulation.

While there's no crystal ball, many patients do eventually come off medication and function well, especially when they develop effective coping strategies and behaviors. Strengthening neural networks through early skill practice can help them compensate for the genetic component of ADHD as their brains mature.

No medication treats the core symptoms of autism. Pharmacotherapy is used to treat 'target behaviors' and associated symptoms, regardless of the autism diagnosis itself. This includes stimulants for attention/hyperactivity, non-stimulants for emotional dysregulation, and SSRIs (like Prozac, Zoloft) for anxiety and rigidity.

Yes, many children, especially those with milder forms of autism (Level 1), exhibit significant strengths. These can include exceptional memory, attention to detail, adherence to rules, and hyperfocus, often predisposing them to excel in technical fields like engineering or STEM, allowing them to lead successful and fulfilling lives.

Closing this gap requires training more professionals, including developmental behavioral pediatricians, nurse practitioners, and allied health professionals, and creating innovative teams. It also necessitates better reimbursement structures and, critically, bridging the healthcare and education systems, as many issues manifest in schools and require integrated support.