Speaker 1: 0:04

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden .

Speaker 2: 0:20

Hey everybody. Dr. David Hilden here. And this is episode 14 of the Healthy Matters podcast. Thanks for joining us today. We are gonna talk about autism. To help me out, I've asked Dr. Christian on Subramanian. You might remember him from episode one of season two. He is a pediatrician here with me at Hennepin Healthcare in downtown Minneapolis. We're gonna talk about all things autism, about, what is it, how common is it? And what is life like for people living with autism? Dr. Kris , thanks for being back on the show.

Speaker 3: 0:52

Uh , thank you so much Dr. Hilton , for having me. Um, and, and thanks for highlighting some wonderful neighbors of ours, neighbors who have autism and, and the community of incredible people who are doing amazing things. I'm

Speaker 2: 1:03

Really excited to talk about this very topic, and I love the way you just framed that. Start us off, what is autism? Yeah.

Speaker 3: 1:11

So autism is a neurodevelopmental disorder or difference that changes and affects the way people communicate and behave. So digging down on that a little bit, there's a communication piece and a behavior piece. When we think about communication, we think about language. You know, one of the jobs of pediatricians is to monitor development. We're asking, checking in with families about how is your baby communicating? And at the earliest stages, that's about how are they making sounds or looking at you. And then as they get older, it becomes how are they communicating with words or language , uh, or in other ways. Uh, one of the things when it comes to autism is that there are differences in the way that children communicate. They do a little bit different back and forth communication. Right now, you and I are having a conversation, and we're going back and forth. Some kids with autism don't do that quite as much. They don't go back and forth with communication. They have differences in the way they communicate with non-verbal communication. Um, we oftentimes use our eyes and our smiles and to, to convey emotions in autism. Children and , and adults frequently won't do that. Also, we note that , uh, there's a difference in understanding of relationships. So kids with autism or, or adults with autism may do a little bit less imaginative play. They may have some differences in the way they make friends and , and the way they communicate with those friends. So that , those are all sorts of , sort of the communication pieces we think of. And that's

Speaker 2: 2:47

Only half of it. That's

Speaker 3: 2:49

Half of it. So you, you know, when we talk about diagnosing autism, we, we tend to see those symptoms. And then there's another few behavioral symptoms that we'll see in young people who have autism. So there may be some repetitive behaviors. Kids and adults may focus on certain behaviors that they wanna repeat over and over again. It may be certain motions, certain objects and things that they like to play with and do. Additionally, there may be a , a highly regimented behavior. So some kids or adults may really want things in a certain way. They want things lined up in a certain way. They want their room to look a certain way. And that is one symptom we think of when it comes to the behaviors. Also, some kids and adults who have autism may have very specific interests. So a certain type of animal or a certain type of object or vehicle, cars, trains that they really like. And that is a type of repetitive behavior that we see , uh, in folks with autism. And then , and then finally, very importantly is people with autism may have differences in the way they have sensation. They may be very sensitive or differently sensitive to touch to certain tastes, to certain textures. And so when you put this together, autism represents a difference in the way people communicate and behave . That can sometimes get in the way of the way they're able to communicate with others.

Speaker 2: 4:14

So you used a couple of words, I'm gonna go back to you used it might be a disorder or might maybe more accurately be reflected as a difference. Yes . Is it a disorder at all?

Speaker 3: 4:26

So right now we diagnose autism with something called the D S M five. It's a diagnostic and statistical manual. And it asks, do you see these criteria in a young person? And in particular, a couple caveats , uh, on that diagnosis. Uh, we should see some of those symptoms at an early age. We should also see some , uh, effect on their daily life to call it autism spectral disorder. Mm-hmm.

Speaker 2: 4:54

<affirmative>. So

Speaker 3: 4:54

That , that may be the key difference, is that does it have some effect on their daily, daily life and the way that people engage in that daily life. I think a lot of the things we just talked about, Dr. Hedon , whether it's differences in the way we communicate, liking things a certain way, having different sensations are things that you might see in a lot of people. Mm-hmm. <affirmative>, I think it's when you collect them, and then when it begins to have some effect on folks daily lives, that's when you can call it a , a disorder. But , uh, there is a , there's a large spectrum. There's a large spectrum. And , uh, it is , uh, encompassing of a lot of people in a lot of , uh, different ways that autism may manifest.

Speaker 2: 5:32

So you used the word, the spectrum, and many of us have heard this term before. Um, in fact, maybe some of us even use it in our daily lives . Oh, he or she's , uh, on the spectrum maybe without really knowing what we're talking about, first of all, is that an accepted term? And second of all, what do we mean by that? Yeah,

Speaker 3: 5:49

I , I , I hope that the term autism spectrum is seen as an encompassing term to represent really the beautiful diversity of people who have autism and frankly, the beautiful diversity of people who, who live in our community. Because we just talked about , uh, a variety of symptoms. We talked about some communication symptoms. We talked about some behavioral symptoms. And the truth is, every single person with autism, the millions of people in our country who have autism, have a slightly different version of that. Um, some may have differences in the way they communicate with language. Some may have , uh, certain strong preferences around sensation. Some may have strong , uh, preferences in the way things are laid out. So

Speaker 2: 6:28

You can't just say, here's what it always looks like in every person. And

Speaker 3: 6:31

Every single one of our neighbors with autism has a slightly different variation of that. And that is representative, I think, of the spectrum. But then I also think there's a , an element of the spectrum that, that represents. Some people with autism have very little effect on their daily lives. It affects their daily lives, but, but not in a way where they need significant levels of services from other people to get through daily life. Whereas there are other neighbors who have autism who really need a lot of support to do their daily functioning and daily life activities. And so I think that is another level of the spectrum, is that there are various levels of, of intensity of services. And so I hope the term , uh, spectrum allows us to see that every individual with autism is different, has different needs. And, and really one of our responsibilities as providers, as community members and as neighbors, is to get to know every individual and find out what are the ways that we can support that individual.

Speaker 2: 7:25

Yeah. That is so powerful. What the way you frame that, I really, really like that. But do we know what's happening in the brain for people with autism? And , and , and I guess that's another way of saying, do we know what causes this?

Speaker 3: 7:38

Yeah. So let , let's start with the brain and then I'll, I'll turn into like, yeah . What , what co what causes , um, you know, there's some very large scale evidence from, from brain imaging to suggest that there might be some, some consistent patterns. Uh, so maybe people with, with autism have slightly smaller hippocampus, slightly enlarged amygdalas, different parts of the neuroanatomy that are, are slightly different over, over the large scale. One thing that's really interesting is seeing, they , they're using MRI now to map connectivity of pathways, which is just beautiful science and beautiful imaging. And you can see the way that different parts of the brain connect with each other. One of the things , uh, that is seen is people with autism actually have very individualized idiosyncratic patterns. So they have maybe very strong visual pathways or very , maybe very strong connections between visual pathways a and language. So they may have very unique strengths within their brain pathways that are really re uh , really strong. And that's, it's , that's a cool thing to see that our , our neighbors with autism have, have some incredible unique strengths that are visualized in the brain.

Speaker 2: 8:54

You can actually see them on advanced imaging like an mri . Yeah.

Speaker 3: 8:57

Yeah. There's, there's a , there's a professor out of Colorado State named Temple Grandon . She has autism and , uh, speaks, she , she studies animal sciences, but she speaks a lot about living with autism and, and what , what we can do to help our neighbors with autism. And she talks about how her, she , her visual cortex has been , uh, mapped out. And you can see in the imaging, it's just so much bigger than, wow , frankly, yours are my , you know, yours are mine, David. Um, but it's, it's a remarkable thing. But, you know, Dr. Granton also talks about how that these strengthened pathways in whatever way they are, are , are the seeds of some incredible things in our community. You know, we, she talks about , uh, a , a young Albert Einstein, you know, and a young Albert Einstein didn't talk till he was the age of three. Mm-hmm . <affirmative> , he liked his blocks in a certain way and lined them up in a very certain way. Would he have been diagnosed with autism? Very likely. You know, very, very likely. And,

Speaker 2: 9:51

And is not what people call the genius. If you think of a genius, you think of Einstein a

Speaker 3: 9:55

Absolutely. The , the prototype of a genius that

Speaker 2: 9:57

Prototype. And

Speaker 3: 9:58

What does that mean? It means that sometimes these symptoms that we just talked about, this, this, this focus on certain things, this interest in certain things , uh, it can sometimes be the seeds of the things that change the world.

Speaker 2: 10:09

Absolutely. So what causes

Speaker 3: 10:11

It? So maybe it's easier to tackle Dr. Hilden . What does not cause , what does not cause, what does not cause autism? Um, I think there's been a lot of talk about autism over the last 30 years. And , and one of those talks has been, oh, is it vaccine related ? I think one thing we can say with as much proof as there is under the sun,

Speaker 2: 10:30

As certain as we can possibly be

Speaker 3: 10:32

A , about anything that , uh, vaccines don't cause autism. And , and I, and I wanna make that a as straightforward as

Speaker 2: 10:38

Possible. I appreciate you laying that out there ,

Speaker 3: 10:41

<laugh>. So, so vaccines don't cause autism. And, and I , I also think we oftentimes run, and I know parents often think about what did , what , what am I doing? What did I do? Yeah . Is it , uh, no , we , we know. It's not something that parents are, are consuming or doing. You know, this is not about, it's not about parents. We think, and we know that there are , uh, there's a genetic component to autism. The challenge with that, Dr. Hilton, is that there's over a hundred different genes that have some connection peripherally or more strongly to autism. And so to try to synthesize that, it's, it's a difficult thing because there's, it is so multifactorial.

Speaker 2: 11:18

I love your message though. It's not what you did, folks, you know , parents, you didn't do this. Know your vaccine, do and do it, and nothing you did. You don't, this isn't your , something you're responsible for. It's nothing you personally did.

Speaker 3: 11:30

Uh , no. And , and you know, we , we also know that there's a, there is a genetic component because we see that in, we do see it in families . So we will see, for example, in in siblings, there's a higher preponderance or concordance in , in twins of a sibling having autism, and then , uh, you know , their sibling having autism. Right ? Um, so, so we know that there is a genetic component. We know that there's some , um, some correlation, though the science isn't great about paternal and maternal age. The older we get as we have children can have some correlation. But the truth is, Dr. Hilden , I, I think here, here we see a hundred genes. We see , uh, brain connectivity in certain spots. I , I think if we have young scientists and researchers out there who really wanna push the boundaries of knowledge, I , I think one, learning the brain generally is, is the new frontier. And is the frontier of where, where science is going. But I think autism in particular is another space that we have a lot to learn and how you uncouple these hundred genes.

Speaker 2: 12:28

When we come back, we're gonna talk about diagnosis and then we're gonna talk about living with autism. Stay with us. We'll be right back after a short break.

Speaker 1: 12:37

You are listening to the Healthy Matters podcast with Dr. David Hilden . Got a question or comment for the doc, email us at Healthy Matters hc m e d.org , or give us a call at six one two eight seven three talk. That's [inaudible] 8 7 3 8 2 5 5. And now let's get back to more healthy conversation.

Speaker 2: 13:01

You , you used the word earlier that millions of Americans have this, so how common is it? Yeah,

Speaker 3: 13:07

Right now they're saying , uh, as of this year, one in 34 children are, are diagnosed. So we're talking countrywide. About 2% of Americans have autism or on the autism spectrum.

Speaker 2: 13:18

Is that on the rise on the fall? Is it the same?

Speaker 3: 13:21

If you had asked me this question in 2000, Dr . Hedon , we would say one in 150 Americans. So I would,

Speaker 2: 13:28

That would conclude It's on the rise. Is that wrong? You

Speaker 3: 13:31

Would, you would be accurate that the number of diagnosed people on the autism spectrum is on the rise now? Was it that we were underdiagnosing, did we not recognize? Uh , I , I think that's a huge piece of it that

Speaker 2: 13:44

Seems like it's enormous, that we simply weren't identifying it as much. And this

Speaker 3: 13:48

Is a relatively young field, Dr. Hilden . Yeah . You know, it , it wasn't until 1940 that the first sort of description of 11 kids with some varia variation in communication , uh, was described. And then, you know, it wasn't until the , you know , 1970s, eighties till you got a little bit more discussion on that started to, to recognize. And the amount of education we've done to providers, the community ha , has been enormous. And I think that's a huge reason we're starting to identify , uh, more folks with some of these symptoms, you know, landing on the autism spectrum. I think it's also part and parcel, and I know we're gonna talk about this, of we're recognizing more and more, and , and this is part of the research advent, it's part of the clinical advent , is that we need to make early diagnosis to help folks along their path, right? We need to make the diagnosis in order to get them services and the kinds of therapies that, that will benefit them for the rest of their lives. And so, I , I think we as providers are learning a lot. Our diagnosis is getting better. The community knows a lot more. And , and so I think all those things have, have seen a shift from one in 150 to one in 34. Is

Speaker 2: 14:55

It more common in certain people are at some groups more at risk, are boys or girls more at risk? Mm-hmm. <affirmative>, talk about that if you could please.

Speaker 3: 15:03

Yeah. So, so you know, we talked a little bit about how families, if you have a , a member of your family , uh, and a sibling , uh, a parent with, with autism, then that is, is a risk. Uh, we know that it is more commonly diagnosed in boys four times as much diagnosed in boys . So it's, it's a pretty big dis disparity in our diagnosis. We don't have a great reason for that Exactly. But I think it does beg the question of are we diagnosing it well and consistently, and it's something we need to be thinking about a lot. The population rates are very comparable across the world. That's just looked at a map that mapped out by color on , you know , shading color on the map, the rates of autism. It was a uniform map for the most part because it was a , just about the same when no matter where you went, there's some slight variation. France has the lowest diagnostic rate and Qatar has the highest in the , in the world. However, it is not a huge disparity when you compare it to, to other types of illnesses in the disparities. And if you look at, in the United States, if you look at , uh, autism rates by race and ethnicity, remarkable. And I have it here with me, David, I want to hear 2.1%, 2.2%, 2.2%, 2.3%. And that's across different

Speaker 2: 16:14

Racial groups. Across racial groups. So it is the same remarkably, almost identically the same across racial groups. It ,

Speaker 3: 16:21

It , it's remarkably similar. And, and

Speaker 2: 16:23

That's shocking to me. It it

Speaker 3: 16:24

Is, it's, it's, it's a surprise. Now, I will say, I , I think if we we're looking at diagnoses , um, yeah , we know that our data suggests that we are slower to make the diagnosis in African American and people of color. So it's, it's a disparity that we need to address and we need to get better at. And that, that's partly outreach. It's partly our conversations and, and making sure we're doing a good job of, of screening and diagnosing.

Speaker 2: 16:49

How is it diagnosed?

Speaker 3: 16:50

There's a few ways that we approach this conversation. One, and , and it's always so welcome . And one of the things I wanna encourage every family out there is, one, talk to your kid. Play with your kid , sing to your kid. Uh, have have a lot of conversations with them and then check in with the c d t. Check in with your pediatrician about what are the kinds of things that we would expect a child at any given age to do. And this starts from birth two months, four months, nine months, all the way through and just is my child doing the things that I would kind of expect? And

Speaker 2: 17:18

Parents don't always know that

Speaker 3: 17:19

A absolutely not. And , and there's some really great apps, there's some really great websites. And then please use your providers as a, as a resource to find out, oh , what should my kid be doing approximately at this age? And there's always variation. I wanna make that very clear. But a at any point if you have concerns that your child is maybe not doing what you would think, bring that up. Cuz that is always a very welcome way to begin a conversation. Well , how do we make this, this diagnosis? First, I wanna make it clear that pediatricians and, and family docs, at 18 months and two years, we'll always do a screening. We'll ask a bunch of questions about development and it'll give us a sense of are there some symptoms that might fall along the autism spectrum? And

Speaker 2: 17:59

You do that with all kids.

Speaker 3: 18:00

We do that with every kid. And , and so one of the great things about screening tools is that we use it with every child. And , uh, we, we get a sense of if there's any clues there. And if there are clues, we'll do some further testing, further questions, and we'll make referrals to some of our colleagues who do deeper testing and deeper analysis to determine whether these communication and behavioral symptoms really are existing. Now

Speaker 2: 18:23

Is that a neurologist or are there people who specialize specifically in autism spectrum?

Speaker 3: 18:29

We , we are blessed with some incredible colleagues and they fall along a couple different avenues and professional venues. So we do have some pediatric neurologists who, who , who will do this. But , uh, more commonly we have incredible psychologists in our, in our community , uh, clinical psychologists, pediatric psychologists who will sit down and do incredible conversations and evaluations with, with young people determining whether they have some of these symptoms. There are , there are standardized scales that they'll use , uh, standardized conversations and tests that they'll do with kids and, and determine whether they fit this criteria for, for autism. But one thing too, David, you don't need to wait for a screen, right? Like we as pediatricians will do the screen and we'll do it at 18 and 24 months. But at any point, if a parent feels a question or a concern, we can always get that referral made to our psychology colleagues, to our neurology colleagues. Uh, we have developmental pediatricians who, who specialize in this space. And they are awesome. They're wonderful. It's a fun appointment in many ways cuz it's , uh, it's a really nice play event and we can get you to those folks , uh, if you have any concerns. So

Speaker 2: 19:35

That , that's the message to parents. If you, if you have questions about your child, ask your pediatrician.

Speaker 3: 19:40

Yeah. And it doesn't matter whether we call it autism spectral disorder, a speech delay, a difference in behavior. If we can get kids more therapy, more practice with conversations and socializations and ,

Speaker 2: 19:52

And the sooner the better

Speaker 3: 19:52

And the sooner the better. Frankly, the label doesn't matter. And it , it matters that we are helping the young people do more and practice more and, and helping parents to help their kid. I'd like

Speaker 2: 20:03

To shift the r the rest of our conversation about living with autism.

Speaker 3: 20:08

So first thing I wanna acknowledge is that I think anytime you give a kid a diagnosis of anything, it it , it's a , it's a shock and it's a , it's a whoa, it's a whoa moment for any, any parent. We as pediatricians, we as a community are there to walk, walk beside families. Um, so there are some incredible resources out there. There's organizations that are supporting families with autism. So there , there's Frazier, there's St . David, there's a number of , uh, Minnesota Autism Center. There's a lot of great organizations right here in our community that are supporting what I, what I think it represents. What does it mean when you , uh, you know, what does life look like? So first and foremost, I think at an early age, it means we're gonna get you the extra support. We're gonna get you the extra therapy, we're gonna do the extra practice. Minnesota and , and frankly, our early child infrastructure is, is really exceptional. Right away we make a , we make a referral to speech therapy, the kinds of therapies that will support , uh, a child with autism, various modalities of therapy that, that help kids learn a lot of the skills we're talking about. Uh , but we also have the school districts, you know, we will refer to the school district who will provide extra therapies and extra support for kids in that first three years and beyond, all the way through their educational career. So I think one of the key elements , uh, for I would encourage all parents to think about is if you get that diagnosis, living with autism means finding the resources that are gonna be supportive and relying on the professionals around you to help you get to those resources. So that's the , that's the first thing. Uh , the second thing I'll say, David, is the spectrum is huge. And for each individual thereafter, it's gonna be, it's gonna be variable. Some kids will need some minor supports in their classroom setting. Some kids will need the, the socialization and friend groups that come from a community and other kids may need significant support. And , and that spectrum can be so broad as we, as we talked about earlier. And so that will look very different for each family. But I think having a navigator, having a someone who will walk alongside you becomes crucial. What about

Speaker 2: 22:05

Things like , uh, social relationships mm-hmm. <affirmative> as children and then into teenage years, they're , you know, where relationships are difficult for all teenagers. Yeah. How do, how do young adults, teenagers manage that? Yep .

Speaker 3: 22:19

So it , it is through various modalities of therapy. It's a lot of what , um, our, our pediatric therapist will work on with kids. Mm-hmm . <affirmative> is how do we make friends? How do we take turns? How do we do the elements that are gonna make us successful in a classroom setting? Uh , I think one of the things I think about , um, our , our pediatric therapists do an incredible job of helping our kids with making adaptations to be successful in their world, right? I think they do an incredible job long

Speaker 2: 22:44

Into adulthood

Speaker 3: 22:45

Then long into adulthood. But one of the things that I think we as providers, one of the things that I think we as a community and, and as organizations can do is help the community understand and adapt and make places more welcoming, more , um,

Speaker 2: 22:59

Absolutely

Speaker 3: 23:00

Amenable, more, more friendly and, and more honoring of our neighbors with autism. A and so I think it's a, it's a simultaneous process of, of supporting our kids, but also supporting our communities to, to learn to

Speaker 2: 23:11

Be a little bit more welcoming. Not all spaces were designed intentionally or otherwise for people living with autism perhaps. So to wrap it up, it sounds to me, Kris , that , um, the world is changing with regard to autism, that there are more resources, there are, there's more awareness at least of autism at least, I hope so. What thoughts would you leave us both for people living with autism and for the communities about what the future should look like with regard to people living with autism? Yeah, I,

Speaker 3: 23:41

I I think we , we don't know , uh, what what will happen next with our kids, right? None of us do. But from an early age, talk to them, sing to them, play with them, love them, love them, love them. And then use the resources around you to help , uh, guide next steps. Yeah. I'm so excited that the community is beginning to realize that, that the autism spectrum is, is wide. It , it's broad and it represents so many of our neighbors with so many different talents. And, and I think what I would hope is that we begin to recognize that everyone , uh, with autism, everyone on the spectrum has incredible talents, incredible gifts, and that while they're working hard , uh, all of our neighbors with autism are working hard to learn skills. Uh, we as a community should be working equally as hard to appreciate the incredible folks that , that surround us.

Speaker 2: 24:29

I will take that to heart. I think that's probably my number one take home message from this conversation with you , Kris , is that the community , um, needs to do its part and it's a privilege to, to do so. What a great conversation today with Dr. Christian Subramanian here from the Department of Pediatrics at Hennepin Healthcare . I have learned a whole bunch. I hope you have as well. If you like what you heard, please share the podcast with your friends, leave us a review, and I certainly hope you'll join us for the next episode. It's going to be a great one. And in the meantime, be healthy, be well, and don't forget to wear your sunscreen.

Speaker 1: 25:03

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show, email us at Healthy Matters hc m e d.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. And finally, if you enjoy the show, please leave us a review and share the show with others. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, an engineered and produced by John Lucas At Highball Executive producers are Jonathan Comito and Christine Hill. Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well .