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What Causes Autism Part 2: What Does The Science Show? · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
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  and discussions for the busy pediatric practitioner.
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  Click on the link in this podcast for free credit that may include CME,
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  MOC, or ethics credit, depending on our topic or podcast.
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  Joining me on the podcast today is Dr.
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  Avinash Bodhapati. He's a child and adolescent psychiatrist.
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  He specializes in neurodevelopmental disorders.
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  Dr. Bodhapati, thank you so much for being here today on Pediatrics Now.
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  Thank you, Holly, for having me here. So we're talking about a hot topic today,
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  and some pediatric practitioners are getting questions from their patients, from their families.
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  The cause of autism.
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  We have right now an episode out by Dr.
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  Mario Fierro, our developmental pediatrician on faculty at UC Health,
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  where he starts out the talk by saying, okay, stop here.
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  If you want to stop here, go ahead, because what I'm going to say is we don't
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  know what causes autism. Would you agree with that?
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  In some ways, I agree with that, because there is no one cause of autism.
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  We know there are several risk factors or associated factors causing autism,
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  but we don't have one single cause.
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  And that's why you say there is some we understand about autism,
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  what causes autism, but there is a lot more to be determined.
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  Neurodevelopmental disorders is what inspired you to become a pediatric psychiatrist?
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  That is correct. I always enjoyed working with the pediatric population,
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  but neurodevelopmental disorders definitely interest me. It's a very fascinating area.
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  In simple terms, autism is a neurodevelopmental condition, which means it involves
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  the brain and the nervous system.
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  It's developmental, meaning the origin of the disorder is during the childbirth
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  or early developmental period, meaning the first few years of life.
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  It doesn't necessarily need to manifest birth.
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  So red flags, sometimes it can be as early as within a few months of birth and
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  sometimes it is recognized only in later years of life when there is higher
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  social demands or expectations.
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  Can you talk about some of those red flags?
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  At early birth not responding to the to the
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  mother you know poor eye contact those are
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  some of the things that you can notice during early periods and then later in
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  life and later in life it again it depends upon the developmental age of the
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  kid and it depends on what situation or environment they're in when they are
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  going to school maybe or play in in the pre-tea preschool school years,
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  it could be like not playing with other kids,
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  having a typical interest or fixated interest.
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  Repetitive behaviors, not recognizing social communication, not understanding
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  relationships, or having difficulty, not necessarily not understanding them
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  completely, but having difficulty in interpreting them, understanding them.
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  And Avinash, when we talk about the causes of autism, what exactly do scientists mean?
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  Are we talking about biology, genetics, environment, or a mix?
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  That's a good question. So definitely a mix of everything.
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  When I say everything, biology, the genetics, and then mind-blowing factors.
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  So talking about the biology, we want to look at, okay, what are the changes
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  in the brain or what is going on in the brain that manifests as these symptoms?
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  Why do people who have autism process things differently compared to a typically developing person.
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  And there's definitely some known changes in the brain, whether it's the neurons,
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  the pruning, there are some differences that we know of, but there's a lot more
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  that we need to learn about.
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  And then when we talk about the genetic and the environmental factors,
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  we want to know about, okay, what are those genetics and what are the environmental
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  factors that impact this biology, what is causing the changes in biology or the brain?
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  So we know there's a genetic role in autism, correct?
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  If there's a child who has autism, his or her sibling has a higher chance of
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  having autism? That is correct.
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  Autism is a very highly hurtable disorder.
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  And some studies have shown that if someone has a sibling with autism,
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  then their risk is they're 20 times more likely to have autism compared to the general population.
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  So several studies have shown, twin studies have shown, that there is like 60
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  to 90% of autism risk is from the genes.
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  Are there specific genes or gene patterns that research consistently shows is
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  linked to autism that we know of?
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  Yes, this is definitely a big area of research.
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  There are about 400 to 500 genes or even more genes or gene mutations that have
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  been identified to be associated with autism.
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  But not all of them carry the same risk. there
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  are some genes or there are certain genes
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  which have a higher risk of causing
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  autism or increasing the risk for autism most of the genes when we talk about
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  the gene patterns most of them are associated the genes that code for proteins
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  that are involved in synaptic meaning the neural which for synaptic connections.
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  Proteins that code for like pruning, cell signaling pathways.
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  So a lot of those are the genes that are associated with increased,
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  Like, will there be a day where there's genetic testing for the possibility of autism down the road?
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  Yes, I think there would be a day. Right now, we test a lot of the kids or siblings
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  who have autism to counsel the parents about the risk.
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  Right now, one of the biggest issues in this area is that there's no one gene
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  that we can say, okay, someone is positive for this gene or has this gene,
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  so they're definitely going to have autism. It just increases the risk, right?
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  It's the gene and environment interaction that causes the outcome.
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  So just because someone has the gene doesn't necessarily mean they're going
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  to have autism. Now, their risk of autism increases.
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  For example, Fragile X syndrome, which is the most common cause of intellectual
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  disability or autism spectrum.
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  Now, not everybody who has fragile legs definitely has autism spectrum.
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  They have a lot of features concerning for autism.
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  Some of them do not have features consistent with autism, but at least 50 to
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  70 percent show ASD traits.
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  Right. So their risk is increased, but that doesn't necessarily mean they'll
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  definitely have autism.
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  Okay. So, Avinash, that leads to my next question.
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  So beyond genetics, what environmental factors are being studied as possible
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  contributors to autism?
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  So in the past few decades, there have been like several environmental factors
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  that have been studied. I would say...
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  Maternal factors, maternal exposures. The main reason is because a lot of the
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  hypothesis is that during the fetal development is when a change is occurring, which causes autism.
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  And so there is a lot of emphasis on maternal factors.
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  One of the biggest factors is parental age. I know a lot of times we focus on
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  maternal age, but it is also paternal age, which age 10-year increase in maternal
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  age, there is about 50 to 20% increase in risk for ASD.
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  Then maternal pregnancy conditions like maternal diabetes, obesity,
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  uncontrolled hypertension,
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  autoimmune disorders, they all increase the risk of a fetus having or an individual having autism.
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  Any idea why that isn't talked about more? We've heard so much about Tylenol in the news.
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  Again, we need to understand we don't want to stigmatize just because someone
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  has maternal diabetes or uncontrolled hypertension doesn't necessarily mean
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  their kid is going to have autism. It just increases their risk.
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  And the same way, I know the focus has been on Tylenol,
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  but we know for certain there is a stronger association with other medications
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  which can cause, when the fetus is exposed to certain medications in utero,
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  there's a higher risk for developing autism.
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  A few examples would be like valproic acid or DAPCODE.
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  It's a commonly used anti-epileptic medication. We also use it as a mood stabilizer.
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  That has three to five times higher risk of ASD.
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  Wow. So, but again, we always have to weigh the risks and benefits because untreated
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  seizures have much more high risk for the fetus compared to valproic acid causing autism, right?
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  There are some medications, some of them are discontinued. Thalidomide is another
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  medication, but it's no longer used, so it's not as much of a concern.
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  Estamilofan and Tylenol, the concern is that it's a very frequently used medication, right?
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  And when they looked at it, since I know it's a big debate, so I'll focus a
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  little bit on that, when they look at it, yes, there is some possible association,
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  but the association is not a very strong association, right?
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  And there are a lot of confounding factors.
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  Even for the mild increase in risk. There's a lot of confounding factors and we don't know for sure.
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  There has been no like good studies done.
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  The counters, you know, it still needs to be, there is a lot more that needs
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  to be done to say okay, does it really increase the risk or does it not?
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  So it is possible, but is it now it's, there's just an association but that
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  does not equal causation.
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  That is correct. A very weak association.
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  I know probably a decade ago or two decades ago there has been concern about
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  SSRIs, the commonly used antidepressants increasing the risk.
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  And when they looked at the confounding factors, maternal depression itself
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  is a risk factor for autism spectrum disorder.
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  But when they looked at that confounding factor and they tried to take it away,
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  then it showed that the antidepressants did not really increase the risk for autism.
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  So are there other environmental factors that used to be suspected,
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  but that have now been largely ruled out that we don't have?
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  For sure. I know one of the big ones is the vaccinations, particularly MMR vaccine.
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  And it has been shown that there is no association and they do not increase
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  their risk, whether it's in the maternal immunization or infant immunization,
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  they do not increase the risk for autism spectrum disorder.
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  And is it true there's no evidence to show any vaccines increase child's risk
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  of autism? Is that correct? That is correct.
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  None of the vaccinations so far have been shown to increase the risk for autism spectrum disorder.
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  On the other hand, maternal infections, they have some increased risk.
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  And even childhood infections, not so much childhood infections,
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  but maternal infections, particularly like the rubella, CMV,
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  they have been strongly associated with autism. Hmm.
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  So not getting vaccinated can cause autism. That's scientifically proven.
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  Not being vaccinated and having increased the risk for infection,
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  which in turn, the infection itself can cause autism.
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  Well, this is all so interesting, Avinash. Are there any myths or misconceptions
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  you'd like to clear up for pediatric clinicians? Hmm.
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  For pediatric clinicians, per se, I know a lot of them are already,
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  a lot of my pediatric colleagues are strong advocates. I know the vaccination is a big thing.
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  The other thing is parents often come to us blaming themselves.
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  Now, learning about the diagnosis of autism spectrum disorder for a child having
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  an autism spectrum disorder is hard for the parents by itself.
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  And then they come in, what did I do wrong? And they kind of blame themselves.
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  I think that's a big thing that we need to advocate for, saying that,
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  okay, nobody, no parent, wantedly does anything, right?
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  There are several things, and you cannot control all the risk factors.
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  So I think the pediatrician should kind of advocate and educate the parents
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  that it's not them that's causing it.
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  That's a great point, Avinash. I know you're a father of two,
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  and I'm a mother of three, and there's so much guilt.
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  It's so hard as a parent to not, whenever one of my kids is sick,
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  I try to think of like, did I, what could I have done better?
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  Or if they're in, even if they're in a horrible mood, I like somehow think it's my fault.
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  Exactly. I think we blame, you know, as parents blame themselves oftentimes
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  and that's, that's, you know, there's only so much that you can control.
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  And there are like several risk factors. It's not like, as I said,
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  it's not like one risk factor.
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  You cannot control the genes all the time. You cannot control what you're eating all the time.
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  I mean, you can make healthy choices, but not necessarily control everything.
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  Is there any, I mean, of course, there's so many processed foods in our environment now.
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  Are there any studies going on or happening about processed foods and any sort
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  of link to autism? Or is that another myth?
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  As of now, there is no strong association or no strong evidence to say that process causes autism.
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  In fact, an interesting thing is that maternal smoking has been shown that it
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  doesn't increase the risk for autism. Now, I know it's a controversial thing.
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  It does increase the risk for other medical conditions, but not really necessarily
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  autism spectrum disorder.
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  Similarly, so far, I'm not aware of any research that states or shows that processed
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  foods are associated with a high risk for autism.
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  They do increase other metabolic conditions and cause other medical conditions,
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  but not necessarily autism spectrum disorder.
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  What are some promising areas of ongoing study? So genetics,
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  the biggest area I would say is the gene environment infraction.
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  That would be the biggest part. That would be the biggest emphasis for further research.
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  And there is a lot of research going on there in that area.
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  Because, okay, what predisposes, okay, a certain gene predisposes someone for autism.
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  But what is that environmental factor and which genes and what environmental
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  factors are predisposing or increasing the autism risk? I think that's a good
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  area where there is a lot of research going on.
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  If we look at the autism as a whole, not just the causes, I think early identification
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  of autism is an important thing which we need to emphasize on.
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  And early recognition is important because early interventions,
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  particularly in areas of social communication, helping them.
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  Training them, teaching them social skills or other accommodations,
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  that has shown to cause difference in functioning.
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  Now, autism is not something that, at least for now,
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  autism is not something that we can cure, but we can improve the functioning
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  of a person or an individual who has autism by changing the course.
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  If we give them early social skills, early accommodations, early supports...
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  Only improves their functioning but it also lowers their risk of developing,
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  psychiatric commodities like anxiety depression what what are the biggest gaps in research,
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  on autism causes epigenetics meaning the gene drug interaction that is a big
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  area again we have a We know there's a lot of environmental factors, and what is it?
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  I think that that's a big area.
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  Avinash, why is it so difficult to pinpoint a single cause?
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  Because there is no single cause, as we said, because there is multiple causes,
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  so it is not something that's caused by one single thing.
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  There is no one single cause for autism.
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  From the decades of research if there's one thing that we
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  can take home today is that there's no one single thing
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  that can cause autism for sure it's a it's a
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  it's a it's multiple things and how
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  would you say for pediatricians and pediatric
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  practitioners in general listening how can understanding the
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  causes of autism what we know and what we don't know how
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  can this help them in their clinical practice so one
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  of the things that we know for sure and i would like to re-emphasize vaccination
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  doesn't increase the risk for autism what excites you most about the future
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  of autism research as far as the causes of autism it would be the epigenetics,
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  that excites me as far as treatment the burial behavioral therapies.
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  Again, my focus is a little different because we look into the behavioral therapies,
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  how to support individuals who have autism to make them as functional as possible
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  without impacting their self-esteem or causing other psychiatric issues.
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  And Avinash, you see patients in several locations.
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  For our pediatric practitioner listeners in the San Antonio,
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  South Texas area, can you quickly mention a few of those? You see patients at Clarity?
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  I see patients at Clarity Child Guidance Center.
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  I also see patients at the NOW Adolescent Clinic, which is located within the
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  main UT psychiatry building. Yeah.
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  Saad, there's animals that, there's dogs who help with the therapy there too.
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  Do you have anything to do with that?
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  I'm not directly involved in that, but we do have a lot of therapy animals.
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  We have a lot of volunteers bringing in therapy animals to assess patients.
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  And the NOW Clinic parents can call to make an appointment. Is that correct?
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  It doesn't have to be a pediatric practitioner, the office staff calling.
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  That is correct. Although you do not require a pediatrician to refer you,
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  parents can just call the NOW Clinic.
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  And that's for patients in Bexar County? That is open for patients in Bexar County.
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  Yes. In addition to that, we also have...
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  Go ahead. Sorry, I was... Are you going to lead into Morgan's Wonderland?
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  Yeah, I was going to say, I also see patients at the dual diagnosis clinic with
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  the Center for Healthcare Services.
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  It is located within the Morgan's Multi-Assistance Center, and it's right across
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  Morgan's Wonderland and Thousand Oaks Drive.
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  It's an incredible facility for all.
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  Morgan's Multi-Assistance Center
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  itself, the number would be the central number, which is 210-817-3935.
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  Great. So if you could leave Avinash Pediatric Providers with one takeaway about
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  the science of autism causes, what would it be?
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  There's no one cause for autism. It is multifactorial.
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  And autism itself is like a huge autism spectrum disorder.
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  We call it autism spectrum disorder for one reason. and it's a wide variety.
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  If you have seen one kid with autism, you have seen only one kid with autism.
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  And so that makes it hard. So instead of focusing on one particular thing that
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  causes autism, we need to identify the risk factors and try to prevent as much as possible.
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  So if there's one point, there's no one cause of autism, don't let parents feel
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  guilty or blame themselves for doing things a certain way. That's what I would encourage.
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  Bottom line, we just don't know, but if it is Tylenol, there's a very small
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  chance if that, or is that even going too far to say?
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  Based on the knowledge that we have or the information that we have so far,
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  the risk, if at all there exists, there is a very, very, very weak association. Let me put it that way.
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  Okay. It doesn't. So if someone needs Tylenol during pregnancy,
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  discuss with the doctor, and I would say take it.
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  Be the risks and benefits and take it. Thank you so much for your advice.
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  And we have in our Pediatrics Now news feed an episode on vaccines.
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  And our sister podcast is Pediatrics
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  Now for Parents. We will have a short episode with Dr. Bodapati.
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  So we'll have an episode with you there where the pediatric practitioner can
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  say, hey, here's this podcast for parents. And if you want to know more about
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  the causes, what we know and what we don't know about autism,
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  that's on Pediatrics Now for parents.
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  Is there anything you want to mention before we wrap up?
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  Avinash, this has been so insightful. I feel so honored to be able to talk to you here today.
• 23:37
  No, I really appreciate the opportunity, Holly. I think this is a very important topic.
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  Again, there is, as I've said it earlier, there is some that we know about autism.
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  There is a lot more that we need to do.
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  If you know anyone who has autism, I would like to say that they just process things differently.
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  It's not, I do not consider it a disorder. A lot of kids who have autism spectrum
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  disorder have a lot of strengths.
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  And again, each individual should be identified with the strengths that they
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  have. That's such a great point to stress.
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  Dr. Avinash Bodhapati with UT Health San Antonio, thank you so much for being
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  here today on Pediatrics Now. Thank you.