Conan Gasque (Host): Welcome to Inside Pediatrics, a podcast brought to you by Children's Hospital of Alabama in Birmingham. I'm Conan Gasque. Today's topic is Autism Spectrum Disorder, also known as ASD. Recently, we recorded a video roundtable discussion on this topic with Dr. Allison Battaglia and Dr. Laura Stoppelbein. Both are licensed psychologists here at Children's.

In our conversation, we talked about the impact of ASD, early warning signs and what parents need to know. Here's my discussion with the two experts.

So I want to start this conversation by talking a little bit about ASD from a perspective of defining it. I know it's something that the vast majority of people are familiar with in one way or another, but Dr. Battaglia, can you tell me a little bit about what all it includes? What falls under the umbrella of an ASD diagnosis?

Allison Battaglia, Ph.D.: Yeah, so autism is a neurodevelopmental disorder that impacts a person across the lifespan. There's two areas that we particularly look for, is impairments in social communication as well as the presence of restrictive and repetitive interests and behaviors.

When it comes to the social communication side of things, kids or adults with autism typically have difficulties engaging in various social skills. Things like understanding emotion in their self and others, reading nonverbal cues, having reciprocal conversations with people and understanding another person's point of view as well as just difficulty overall making and keeping friendships.

For the restrictive and repetitive behaviors, we'll often see rigidity in relation to routines; needing to follow those routines in a very strict way. They'll also have difficulties making transitions or with changes in their routines. We'll see repetitive motor movements or repetitive play occur with these individuals and they'll often have sensory sensitivities to various aspects of their environment.

Host: So there are a lot of different ways that a person can be affected by this. Do you find that some patients are affected by one aspect of it more than others? Does it vary a lot from one patient to the next?

Allison Battaglia, Ph.D.: Absolutely. There's actually a saying that we use a lot. If you've met one person with autism, you've met one person with autism because the presentation can be so different from one individual to another. Someone may have more difficulties with the social interactions and less difficulties with those restrictive and repetitive behaviors and vice versa and even difference in difficulties within those two areas.

Host: So I guess, with both of you being a licensed child psychologists, I guess it's very important really getting to know each individual patient and kind of finding out what they're dealing with.

Laura Stoppelbein, Ph.D.: Yeah, that's definitely true and there's different, I call it kind of flavors of autism where maybe there's some commonalities and everyone has kind of these same underlying concerns or deficits, but each individual child has personalized needs. Each individual adult has personalized challenges and supports that they need. So really kinda getting to know your client or your child or your adult that you're working with, and understanding what their needs are is really key to working with this population.

Host: And I know that it can affect someone across their lifespan. I want to take a look specifically at ages one through three. Dr. Stoppelbein, what are some of the early warning signs that a parent might want to kind of be mindful of?

Laura Stoppelbein, Ph.D.: Sure. So again, as Dr. Battaglia said, it's a life course disorder. And typically when we're making a diagnosis, we always want to document that those symptoms were present early in development for that child, or for that adult. But if you're the parent of a child of this age, you may want to also be on the lookout for something.

So some of the kind of key things, are response to name. So before the age of two, a child should be pretty consistently responding to their name. Interest in people over objects. So, children are natural kind of explorers. They're kind of naturally curious about their environment and so they have a lot of different things that you see them be interested in and pick up and engage with.

But they should show more interest or more engagement with other humans, than maybe they do with other objects or toys. You're going to want to look at their ability to kinda develop some nonverbal communication skills. So again, kind of by the age of two, definitely you would expect them to be doing some waving.

You want to look at things like, are they giving you a social smile? If you smile at them, are they able to smile back? So a lot of those kinds of social things. And then you can also look towards how they play. So, early in development, it's not unusual to see kids kind of play in a repetitive manner.

They're learning about their world. They're doing a lot of cause and effect play. But as you move through that kind of one to three age period, you should see that kind of falling back and a little more kind of social type of play going on. And some early development of pretend play. And so if the play continues to be very kind of repetitive, very much kind of cause and effect and less of trying to do things like show you things, engage you in their play, want you to be a part of what they're doing and watching them. Right. Those are all kind of some of the early warning signs, that we look for in children, toddlers, in early preschool age for autism.

Host: Is it generally diagnosed at that stage or is it not diagnosed until later?

Laura Stoppelbein, Ph.D.: Yeah, that's a really good question. So we can diagnose as early as 18 months. And really diagnosing earlier is critical because the area or the time period that we'd like to target for intervention is kind of that two or three years old to six or seven years old. You kind of get a lot of bang for your buck if you're targeting intervention at that age.

Unfortunately, most kids though, are not diagnosed until closer to four or five years of age. And that's kind of nationally. Within the state of Alabama, it's probably even a little bit later than that, just because we don't have as many resources, we don't have as many trained providers, and we have really long wait lists for most of the people seeking autism related services of any kind, whether that's assessment or therapy services.

Host: Okay. So, let's say you get to the point as a parent that your child is diagnosed, or, or maybe they're not diagnosed yet, but they're in that one to three age range, and they're starting to show some of those early warning signs. What Dr. Battaglia should a parent do at that stage? What should their first kind of strategy be?

Allison Battaglia, Ph.D.: Absolutely. So if there are early warning signs and the child hasn't been diagnosed yet, certainly, contacting providers that can do that evaluation. So that way they can start getting on wait lists and be able to get that completed. Once a child has that diagnosis, especially at the early age, we really recommend families getting connected to early intervention services.

They're going to be the best resource for those families for the kids that are really young. For kids who are older, we recommend reaching out to the school districts so that way they can get access to special education services in the school system. But additionally, the services ultimately for each kid really depends on what their needs are.

And so hopefully the evaluation has helped families figure out what some of those needs are and they can seek those services based on those needs. In particular, kids often will benefit from speech therapy, occupational therapy, and physical therapy depending on what their needs are.

For autism, probably the most well-known therapy is applied behavior analysis or ABA therapy. That does tend to target that two to three to six to seven age range that Dr. Stoppelbein mentioned. And so accessing those services can be really helpful. Again, we have really long wait lists for those services, so, it's not always the easiest thing to get into. But we do also recommend trying to access general behavior therapy, especially for parents. Getting parent training type therapy so that way they can have a better understanding of autism and be able to address those behaviors at home even when they're not getting that in-clinic service as early.

For our older kiddos, though, we recommend getting them connected to cognitive behavior therapy if there's additional issues with mental health, problems like anxiety or depression, they can benefit from those types of services as well.

Host: So I guess whatever age they are, it's good to act fast, I guess, to go ahead and get involved in some of those things.

Allison Battaglia, Ph.D.: Mm-hmm. Yes, absolutely.

Laura Stoppelbein, Ph.D.: The other place they can also address some of this is with their pediatrician. There are standardized times at which pediatricians are now recommended or kind of required now, but it's recommended for them to evaluate for autism at 18 months, 24 months. And so if parents have concerns, they can talk to their pediatrician about, what did my child's, usually it's the MCHAT. What did my child's MCHAT look like? Or do I need to do this? He's almost 18 months old, or he is almost 24 months old. And that can also be maybe a point of at least guidance as to what next direction should be for really young kids.

Host: Is that a sort of a good first step? Just, you know, go ahead and talk to your pediatrician about it and find out what they say you should do next maybe?

Laura Stoppelbein, Ph.D.: Yeah, I think they'd be a good point of service to begin with, to help guide you and give you ideas about what resources are available in your area. Obviously across the state of Alabama, resources vary widely. So more rural areas are going to have much fewer resources, and so I think the pediatrician should be well connected enough to be able to guide you into which direction and where are some options for you and your family.

Allison Battaglia, Ph.D.: In addition to that, we have in the state, the regional autism networks. There's five across the state and each one serves a part of the state and they provide great resources that a family can reach out to them and they are able to talk the family through what resources are available in their particular area. And that's through the Alabama Department of Mental Health runs those RAND services.

Host: And I know we also have the PATHS program here at Children's of Alabama. Yes. And, and I know you're part of that, Dr. Battaglia. Yes. Can you talk about for the listeners who might not be familiar with that, what it is and how that might help a parent of a child with ASD?

Allison Battaglia, Ph.D.: Absolutely. So our PATHS program stands for Pediatric Access to Telemental Health Services. It is a program that is grant funded where there's three levels of services that are provided. There's echo sessions that help pediatricians gain knowledge on various topics related to mental health. There is a echo dedicated specifically to autism that Children's does as well outside of the PATHS program.

 But then there's a consultation line that pediatricians can contact. So if they feel like they have a patient where they need more information or help with guidance for that particular patient, they can call and talk to one of our psychiatry providers or psychologists, or one of our social workers to help them a little bit further.

And then the third line of service that we provide is actually telehealth services. So a family can get connected to either psychiatry services or therapy services through telehealth where they go to their pediatrician's office and can connect there. So they're not having to travel as far to get access to those services.

Host: Just one of many services that we offer here at Children's of Alabama. We'll talk about those again in just a second. But I wanted to talk first a little bit about, and kind of reiterate a little bit since we've already sort of hit on this, but Dr. Stoppelbein, what are some of the associated challenges and concerns that people with ASD face?

Laura Stoppelbein, Ph.D.: Yeah, so there's a host of different medical and psychiatric comorbidities that we often see with children and adults who have autism. Within the kind of medical side of things, often GI issues are problematic. And along with that, feeding and eating concerns, sleep issues, seizures or epilepsy.

And so, those are kind of common medical comorbidities that we also see. And then on the psychiatric side, we also see a lot of ADHD, learning concerns. Intellectual disability is not as common as we thought it used to be. There's about 30% of our children with autism or so around a third or so have also a comorbid intellectual disability.

But as well as just as they get older, you see more kind of anxiety and depression also develop. And not that you couldn't see that in a younger child, adolescents, tend to be kind of at risk, who have autism have higher risk for anxiety and depression as well. So those are kind of the diagnosable concerns.

Yeah. But then you also have a lot of other kind of peer related concerns, challenges with completing adaptive or kind of daily living behavior. Difficulties in just kind of community living sometimes, just depending on their level of cognitive functioning and their level of social understanding, right?

Social impairment can impact and be pervasive across any area of that person's life, and impact how well they're functioning in that area. And so, you see a lot of other kind of maybe non diagnosable, but comorbid concerns, that our individuals with autism often have.

Host: Sounds certainly very complex. Does that complexity of it and the fact that it can be very different from one patient to the next, does that make it challenging, not only on the patient and the parent, but on you as medical providers as well?

Laura Stoppelbein, Ph.D.: Yes, it's challenging, but challenging in a good way. And we know that, even though there are differences and lots of differences in diversity within the autism community and people with autism, we know that there are certain things that are evidence-based supports and therapies that work. And so, just knowing how to maybe kind of tailor those interventions and how to be creative with using those interventions, right is where the challenge comes. But if you kind of like being creative and having that side of your brain work along with just kind of the regular medical side, then it's kind of a fun area to work in.

Host: And of course we offer a lot of those resources here. Can you talk a little bit about that, Dr. Battaglia?

Allison Battaglia, Ph.D.: Yeah. So, the hospital as a whole offers a wide range of services for children with autism, both for the medical side; full range of medical care for children with autism, just like any other patient that would come through. One area that I think is really awesome that our hospital provides is a sensory pathway.

 So for individuals with autism especially, but other individuals who have sensory sensitivities or needs, we have a pathway that they can follow, where they can get added supports to help meet those needs within the hospital system. Things like noise canceling headphones, weighted jackets or blankets, as well as visual supports to help them understand what's going on.

And our Child Life Services Department really works very well with the sensory pathway to help provide those services really across a wide range of departments across the hospital. And they're able to really help provide some comfort for kids who have autism by helping them be able to cope with whatever upcoming medical procedures are occurring.

We also have a resource of different social stories that are used to help teach kids about different medical procedures that they may be getting at the hospital, and that can be really helpful so they know what's going to be happening to them. At Children's Behavioral Health specifically, we have our inpatient unit, who provides individual behavior plans for kids with autism that are on the unit, including visual supports that may be needed.

In our outpatient department, we provide parent training services. Currently we're doing that in a group therapy model, mostly. We provide individual behavior therapy, individual cognitive behavior therapy to address those mental health issues. And currently we are providing some diagnostic services.

We are hoping over time that we can continue to expand that as we increase our capacity.

Host: We do a lot already and we're always working to do more. Right?

Allison Battaglia, Ph.D.: Absolutely. Yes.

Host: Well, a very good overview of ASD, Autism Spectrum Disorder and the things that we do here at Children's of Alabama, to help patients and their families with it.

Once again, Dr.s Allison Battaglia and Laura Stoppelbein. Thanks so much for your time.

Laura Stoppelbein, Ph.D.: You're welcome.

Host: Thanks for listening to Inside Pediatrics. For more podcasts like this one, go to children'sal.org or wherever you find podcasts.