Scott Webb (Host): Diagnosis of autism in a child is perhaps the most difficult conversation that a pediatrician can have with parents. And though there's much that isn't known about autism, the American Academy of Pediatrics says that, if a child is diagnosed before the age of 24 months and every effort is made by parents and professionals to help the child to overcome their developmental delays, the children can begin kindergarten often without a diagnosis of autism.

And I'm joined today by Dr. Sumit Sen. He's a pediatrician with Stanford Medicine Children's Health and he has decades of evidence-based experience in diagnosing and treating autistic children.

This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Doctor, it's so nice to have you here today. We're going to talk about autism. And as I was mentioning here before we got rolling, autism, I think, is one of those things that a lot of us believe we understand. There's been so much in the news and social media and so forth, but I think it's really important to have an expert on. So, it's great to have you here. And I just want to start there. What is autism?

Dr. Sumit Sen: Autism is a developmental situation caused by differences in the brain. People with autism often have problems with social communication and interaction, as well as restricted or repetitive behaviors or interests.

Host: Yeah, I think it's good to have that foundation there just to have an understanding of basically what autism is. So that being said, what are the signs and symptoms, whether it's for parents, caregivers, grandparents, whomever, how do we spot autism or when do we begin to suspect that autism might be something to consider?

Dr. Sumit Sen: One of the first findings appear in infancy and can appear as early as four to six months of age where the baby is not quite looking back and forth between two adults talking in the room and transferring attention from one person to another. That's one of the earliest signs. By 18 months of age, a child is expected to have a vocabulary of at least a minimum of 10 meaningful words. And less than 10 meaningful words, we would suspect language delay that frequently children with autism have. And lastly, repetitive behaviors where the child is interested in playing with the same toy or doing the same thing over and over again and being interrupted leads to the child getting upset. So, those are the three biggest things.

Host: Biggest things, as you say, and things that parents might notice early on. I'm a parent, I have two kids, and our son loved to play with balls when he was a kid, when he was little, in that 18 months range, somewhere in there. And he had this big basket of balls, right? And he would do the same thing over and over. He would take each ball out and he would turn to me and he would say, "Ball," and then he would throw the ball. And then, he would go over and over and over until all the balls were gone. Then, he would put them back in and he would start over and he didn't like to be interrupted. And I guess my point, doctor, is that it was probably a difficulty for parents, as you're saying, to hear some of the signs and symptoms. But some things are just kids being kids. There's something unique about, you know, their interests, their personalities. Is that one of the issues for parents in even knowing whether it's time to seek help? Is understanding, "Is this just my kid being who they are or is there something else"? Is autism something to consider?

Dr. Sumit Sen: So taking your example, the concept, the first one I mentioned is a concept called joint attention. And a typically developing child will look back and forth into the eyes of the parent as well as the basketball and back again in a very flexible way and show what is called shared enjoyment, meaning, "Look, daddy, I'm having fun. And are you having fun with me?" And so the child at that point, looking back and forth between the object or event, in your case, the basketball and your eyes and ,connecting with you in the mind and exchanging emotional expressions versus some parents will describe as like, "My child is lost in his own world, is stuck with doing the basketball as if nobody else exists in the room" and that was the big difference. So, what we look for when we test is this reciprocal social interaction and joint attention.

Host: Yeah. And that's exactly how it was with my son, is that shared enjoyment between the two of us as he, you know, picked up each ball and threw it. And I'm really glad to have you take us through this, because I think that parents have these questions, they have these concerns. So, you've gone through some of the signs and symptoms when I gave you my own personal sort of anecdote there. When should parents seek help?

Dr. Sumit Sen: So, the most important thing about parents is being closely engaged with their child's developmental progression right from birth. And the reason we talk about that is the discussion of a developmental challenge with a parent is about the absolute hardest conversation that a pediatrician has with a parent way beyond cancer or heart disease or anything like that. And if the parent is very closely engaged with the pediatrician at every well-child visit starting from birth, then the pediatrician who is constantly watching the child's developmental progression will feel comfortable discussing that situation with the parent. Most often what happens is the pediatrician is very apprehensive about discussing developmental challenges with the parent, worried that this would make the parent very upset.

Host: Yeah, I see what you mean. Right. As long as parents are bringing their children to the pediatrician and going for those visits, those milestones and things like that, you know, it would come as no surprise perhaps to the pediatrician because they're going to be seeing some of the same things that maybe the parent has seen at home, but is reluctant to bring to them or to discuss. Are there any risk factors that predispose a child to autism?

Dr. Sumit Sen: The two most well known-risk factors are, number one, extreme prematurity, meaning being born 28 weeks or earlier in gestation. And those babies are routinely screened for autism at the neonatal intensive care followup visits. And also, the second risk factor is having a sibling with autism. The rest of it is still a huge amount of research that is ongoing with unclear answers at this moment.

Host: Yeah. And I'm sure that that's a part of all of this. Any conversation about autism is there are things that are known that you've identified, right? Here are some of the risk factors, but there's just so many things that are unknown. And that's where people get into speculation and maybe listening to talking heads and social media and so on.

So again, great to have your expertise and certainly to understand that there's still a lot to be learned about autism. It's been good stuff today, doctor, educational. I think I know the answer, but from your perspective, can autism be prevented or cured?

Dr. Sumit Sen: No, it cannot be prevented. It cannot be cured. At the same time, the American Academy of Pediatrics strongly emphasizes that it is a treatable condition if diagnosed by 24 months of age.

Host: Okay, so early diagnosis. As so many things in medicine, but especially with autism, early diagnosis is key, right?

Dr. Sumit Sen: That's correct.

Host: Absolutely. Well, doctor, I really appreciate your time today. There are certain topics as a parent, of course, you know, that I want to make sure that we get these things right, that we educate folks. And we obviously want to encourage them. You know, as you say, they would be ordinarily, of course, bringing children in for their regular visits. And that's where a pediatrician might begin to say, you know, "There's some things that I'm noticing here." But either way, getting the word out, educating folks, encouraging them to speak up if they have concerns, that's all a part of this, right?

Dr. Sumit Sen: Right. And the American Academy of Pediatrics have some specific guidelines for parents. For example, by 12 months of age, most children will immediately look at the direction of an object a parent is pointing at, and then they will look back at the parent and mimic the parent's expression, usually a smile. That's by 12 months of age. Usually, children in the spectrum appear to ignore those parent leads. By 15 months of age, most children will point to an out-of-reach object in order to show that to the parent. A child with autism may instead grab a parent's hand and lead the parent to the object without making any eye contact. That's actually a very big red flag. By 18 months of age, most children will continue to point to things they find interesting and ill look back and forth between the object and the parent to make sure that the parent is tuned in, just like your basketball experience, to make sure that the parent is engaged in the child's activity and that the child is experiencing what is called a shared enjoyment. Most children in the spectrum will often point to an object because they want it, but won't necessarily look back or emotionally connect with the child with back and forth eye contact and object and smile together.

Host: So, doctor, good to know that it is treatable, and I want to stay there. You know, you said that it can't be prevented, it can't be cured, but it can be treated if it's diagnosed under 24 months. So, let's talk about the treatment. And then ultimately, if it is diagnosed under 24 months and you do begin treatment, what are the expectations of parents? What are those kids like when they actually start kindergarten, for example?

Dr. Sumit Sen: Research shows that parents who stay closely involved with their child's development even after diagnosis and keep providing developmentally supportive activities at home, then that child has a very good chance of starting elementary school, having lost that diagnosis by that time. The American Academy of Pediatrics talks about the parent being the captain of the therapy team. And the behavior therapists, speech therapists, occupational therapists, and pediatricians, they're all players in that team. With the parent being highly knowledgeable, highly trained, and constantly implementing developmentally stimulating activities at home to supplement all the therapies that are happening gave the best outcome.

Host: Just give you a chance here as we wrap things up, are there any resources that you want to share with parents?

Dr. Sumit Sen: The best resource I'd like to share with parents is a pair of lookbooks. They are called 16by16, published by First Words Project. If a parent Googles 16 by 16 First Words Project And it is two lookbooks that go through in a playful, fun way, 16 actions and 16 gestures a child must do by 16 months of age. And that clues into the 18-month well-child visit when all children are being screened per American Academy of Pediatric Recommendations for autism with the goal of early diagnosis. And that's the best resource I'd like to give to the parents.

Host: That's great. Yeah. And as you said earlier, early diagnosis is key, especially with autism. So, thanks again for your time today. Really appreciate it.

Dr. Sumit Sen: Okay, thank you.

Host: And for more information, go to stanfordchildrens.org. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.