Autism Spectrum Disorder Latent in Young Children
Dr. Jack Krasuski and Dr. Laura Carpenter meet after Dr. Carpenter’s presentation at the Oasis 2019 Child and Adolescent Psychiatry Conference to discuss highlights of her talk about the autism spectrum.
Dr. Jack Krasuski: Dear audience, hi. It’s Dr. Jack, and we’re here with Dr. Laura Carpenter at the Oasis Child and Adolescent Psychiatry Conference. Laura, thank you so much for joining us.
Dr. Laura Carpenter: I’m really happy to be here.
Dr. Jack Krasuski: You’re talking about the autism spectrum in your lecture this afternoon. Just in a few minutes, what would you like to highlight? What do you think is something really important and exciting for clinicians who may not be experts in the autism spectrum but are child and adolescent clinicians and child analysts in psychiatry.
Dr. Laura Carpenter: I think we have this growing awareness that there’s this big population of kids with autism that simply haven’t been identified, and so we’re seeing this influx of kids that come in. I kind of call them the diagnostic whirlwinds, the kids that have diagnoses of ODD, ADHD, OCD, tics, anxiety, depression, and nothing has worked. I think I would like clinicians to be aware that sometimes what’s underlying all of this is autism.
Criteria in Autism Evaluation
One of the complicating factors is that sometimes these kids have had earlier rule out evaluations for autism and what we’re finding if you look at the literature there are kids evaluated by the best clinicians at age two who don’t meet criteria and then later at three, four, or five do meet criteria for autism. Sometimes families will come in and say, oh, we’ve already had a rule out evaluation, it’s not autism. I just want folks to be aware that it’s worth revisiting that issue if they do see concerns.
Dr. Jack Krasuski: What do you think are some of the clinical signs that are missed in those earlier evaluations that maybe become more manifest as the child grows older?
Dr. Laura Carpenter: It’s not so much that they were missed, but maybe at that point, maybe not severe enough to get in the way. As we get older, our social world gets more complex, as you know. Your social demands and social rules become much more difficult. Really when you think about it, it’s amazing that the rest of us learn those social rules so easily. Sometimes it’s just a matter of the child maturing and getting to the point where their sort of limited capacity can’t meet the demands of the environment.
Diagnosis, Treatment, and Access to Autism Treatment
There are two reasons why it’s really important to get an accurate diagnosis. It really does guide treatment and it guides access to treatment. A diagnosis of autism gets you access to different treatments than other diagnoses. I think it also changes the perspective of parents and teachers about the child.
You move from having this very sort of punitive, here’s a child that needs discipline approach to an approach of recognizing, wow, this is a child with true skill deficits. We need to break these skills down into small steps, help them learn emotion regulation skills, social skills, and interaction skills, and also some of the challenging behaviors may be related to the restrictive repetitive behaviors we see in autism. We might see kids that are having meltdowns that are really caused by some of their sensory issues or maybe caused by some of that behavioral rigidity that we’re not even aware is happening.
When you get the accurate diagnosis all of a sudden there is this huge perspective change about the child that can be so powerful. Then, of course, just even having access to a community who understands and supports the families and the people with autism themselves in what they’re going through I think is incredibly therapeutic.
Connection to DMDD, Disruptive Mood Dysregulation Disorder
Dr. Jack Krasuski: I love the point you make. It made me think about the DMDD, disruptive mood dysregulation disorder, and it could be the kid’s kind of irritable all of the time and they’re having temper tantrums all the time. There we go. How can that be wrong? Yet, like you’re pointing out, there might be more to it than that. We have to beyond or behind just some of those behavioral symptoms. What is the underlying cause?
Dr. Laura Carpenter: What’s driving this?
Dr. Jack Krasuski: What’s driving it.
Dr. Laura Carpenter: You know with autism we don’t know for sure what causes it, but we do know what helps. There is a lot of evidence-based treatments, whether you’re looking in the pharmacology world, whether you’re looking in the non pharmacology world, even to the complementary alternative medicine world, we know that there are treatments that work and so in order to access those treatments we need to have an accurate diagnosis.
Dr. Jack Krasuski: Another thing you said that struck me, so that we understand these kids better so we’re not punitive, the teachers or parents or whoever, and it reminds me about three years ago I read this book called NeuroTribes. It was the first time I was exposed to that idea that people are just neurologically different. It just seemed like such a helpful concept that we’re just different. Everyone has their own unique shortcomings and skills. Could you talk more about that concept? It seems very non pejorative. I think is maybe an easier way to even broach the topic with parents who are probably struggling with the disorder of autism.
Claiming Autism as Your Identity, Can Mask Impairments
Dr. Laura Carpenter: I think you’re touching on something that is a struggle within the autistic community because we do have this group of people that very much want to claim autism as part of their identity. They advocate for being called, you know, I’m an autistic adult, rather than a child with autism. It’s a big shift. I respect and I feel that can be very useful. On the other hand, to some extent it minimizes the very severe problems that some of my patients face, really incredibly life changing difficulties. I have patients that have been carted away from school in handcuffs because they are engaging in sexual harassment, and they’re not. It’s part of their autism.
There is a big problem in this country of individuals with autism being charged on child pornography charges and, again, it’s not recognizing those social rules. It’s a big deal. I think to an extent claiming autism is your identity is wonderful and it can be incredibly supportive and incredibly therapeutic. But then I want to make sure we don’t lose sight of all the kids that are so impaired and really in need of help.
Dr. Jack Krasuski: I think I was just reading an article. The posterchild now of autism is a billionaire genius working in Silicon Valley. Well, there are those individuals with Asperger’s but the majority are going to be much more disabled and much more in need of support and understanding and not calling the police in such instances. My gosh, that must be so traumatizing to a child.
Dr. Laura Carpenter: I know. I know. It’s really terrible. You know, I think maybe if our perspective was different and we could figure out a way to channel those special interests, we without have more of those billionaire people because the focus you see in autism can be amazing. There can be some real gifts there, but I think we need to figure out a way as kids get older to channel that energy in the right way. I’m not sure we’re doing a good job yet.
Dr. Jack Krasuski: Laura, thank you so much. I’m really looking forward to your talk. Thank you for being part of this.
Dr. Laura Carpenter: Thank you for inviting me.