PATC+2012_Yerys_Genetics & Autism

Dr. Yerys: Really, I see my goal today is to try to convey to you the excitement that we have at the Center for Autism Research about the sort of what we learned in genetics, where we see the field going. You know, we often cite our associate director's and epidemiologist and he often tells us that there is a 17-year gap right now between when we actually identify meaningful treatments or testing and how it actually gets used in the community and sort of into the general public. And that's a really huge gap. And so, one of our missions in the center is to really communicate more with the community and try to get people more familiar, more involved earlier on in the process. So, I'm hoping this is a step of that.

If you were looking for a full introductory to genetics, this is not going to be what we're doing today. I'm really trying to give you a 30,000-foot overview of a couple of key things that I think are really interesting and where we see a lot of excitement, and then trying to blend that into what we know about brain development and cognition and attention. So, hopefully that will be exciting.

So, you know, the talk objectives today are up here. And so, the first thing I want to talk about is a topic that if you've been following sort of the "New York Times" or listening to autism discussions of late, a huge amount of energy has been spent around sort of this switch to DSM-V and what that might mean for services available to children and diagnosis. And I wanted to touch on this, I'm not sure if other speakers have touched on this today, but so, I did want to spend a little time on this because there is a lot of concern.

So, this is the one slide in your handouts that is completely illegible, and I apologize for that. But I think it's just really nice to see the criteria up against each other. The key things I just want to point out here are that on the left side, which is the current diagnostic criteria, we have sort of social interactions is one domain. The second domain is impairments in communication. And the third domain is restricted, repetitive, and stereotype patterns of behavior or interest. And in order to have a diagnosis of autism you need to have a total of six symptoms with two coming from social interaction and at least one in these other domains. These delays or, you know, atypical functioning has to have an onset prior to the age of three.

And so, this is currently what we have. And there's a lot of concerns. So, the new criteria, which are on the right-hand side, they've sort of only have two categories now. There's what we call social communication and social interaction, and there is a restrictive, repetitive behaviors, patterns of behavior, interest, or activities. And here, you know, you need a total of five symptoms, but you have to have all three in domain one and have to have two in domain two. And this is the really big shift that's going on here.

But if you look carefully at this what you can see is that, you know, one, like I was saying, the communication appears like its gone, but it's really not. The difficulty with this, you know, sort of sustaining a conversation or sort of initiating a conversation, that's sort of just been moved up into sort of social communication. And the sort of difficulties with repetitive speech or sort of stereotype language, like repeating the same phrase over and over again. There's a lot of times you'll hear kids, you know, will have this pet phrase. Like they'll say no to every question but then give you an answer that might -- says yes. Or they'll start every sentence with well, actually. In truth. I mean, these are just examples that I've seen clinically.

And so, that sort of repetitive or stereotype language is actually been moved over here with the other repetitive behaviors.

And then finally, the lack of varied or spontaneous make-believe play has, again, been brought up into sort of social interaction. And really the one thing that's been dropped has been the delay or lack of spoken language. And the reason that that's been dropped is that that really seems to not be so specific to kids with autism. There are many kids that have delays in language, but they don’t always have autism. They have may have a speech-language impairment. They may be kids that develop dyslexia or a reading disorder, but they don’t necessarily have autism or social difficulties.

And so, that was one of the main motivations for sort of moving this away.

So, I just wanted to highlight that, you know, while it seems as if, you know, it's much more stricter here, that you have to have all three, in some sense it's sort of combining a lot of what's here. And so, that's not really changed.

One of the other big aspects that has changed has been down here where there's sort of this requirement that has to have the delays or the atypical functioning has to be seen prior to age three. And what's going to occur now is actually a much broader definition where we'll say the symptoms must be present in early childhood, but they may not become fully manifest until social demands exceed limited capacities. And it's a very, I think, dense, opaque language. But really, I think the important thing is they want to say look, there may be kids that have really high IQs but may still be on the autism spectrum and their sort of cognitive abilities may help support them through preschool and into, you know, elementary school, but it's really when they start getting into second and third grade and social demands start increasing that you start seeing a lot more of these difficulties. And so, they wanted to give the license to that that, you know, if you then interviewed them and then sort of went back into early childhood you might see that there were some of these problems, but they were much more mild or much more subtle. But they didn’t want to sort of knock kids out all the way. So, it's actually a broader definition.

And then the one -- another change that came up is the fourth item in the repetitive behaviors. This is new and one that a lot of clinicians -- and it's basically saying that hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment, such as apparent indifference to pain, adverse responses to specific sounds or textures, excessively smelling or touching objects, fascination with lights or spinning objects.

And these are behaviors that we see all the time in kids with autism, but it was never technically part of the diagnostics before. And if we actually look sort of sensory interests, we actually see that about 90-95 percent of kids with autism have sensory impairments in one direction or another. Either they're hyper-reactive or they're hypo-reactive. And so, we really wanted to be able to capture that since that was present so often and so many families sort of said this is important. This is part of autism. So, this has been added.

So anyway. And in terms of what's sort of causing the largest amount of controversy has really been that this second domain here now has a requirement of two symptoms. And so, I don’t know if anyone have seen this, but there's been a couple articles in the "New York Times" where people argue that something like, you know, 20, 30 percent kids would lose the diagnosis using this new definition. And there's a couple of things to keep in mind. One, you know, the biggest thing that's sort of been driving that has been this little piece right here. Because if you -- in this part, when people look at this aspect, the social piece, it seems to be the case that there's actually not much changed, just based on social symptoms. It tends to be the repetitive behaviors. And what happens is when you require two symptoms the identification of children that really are meeting criteria for

autism is really quite high, but it ends up leaving kids that are more in that gray area, like maybe they're on the spectrum, maybe they're really mild, and when you drop this down to one symptom all of a sudden the difference between DSM-IV and DSM-V goes away. I mean, there's almost no difference. It's almost within the amount of measurement error.

The other thing that's really interesting is when people have been reporting this, this fourth symptom that I've been talking about, this sort of sensory interest, because it was never part of the DSM-IV criteria, whenever people are going back and looking at records they're making sort of a decision about whether a child would meet DSM-V criteria without actually having information on that symptom. So, if you need two in this domain and you only have three out of four options? You've really lost the chance to maybe indicate, you know, whether a child is on the spectrum. Especially, as I said earlier, when 90-95 percent of kids present with some form of a sensory difficulty.

So, that really -- so, I just wanted to keep this in mind because I know it's a really big question that comes up and parents get very upset about this. And hopefully there will be future field trials where people will carry out looking at DSM-IV, DSM-V, when they actually see children. Right now, all the research that's been published is people going back into their old databases, seeing their reports, seeing what's going on, and then comparing, you know, the new criteria and the old criteria and that's not really the same for the reasons I mentioned. Particularly with related to the sensory. So hopefully in the new field trials that will be carried out they will sort of look at this more carefully and really give us a good estimate of how much things will change. And the hope is, is that it shouldn't.

So, the second area that I'll talk about is going to talk about the recent genetic findings. And what I thought I would do is sort of talk broadly. Just give some definitions about genetic terms and certain ways that we sort of probe genes and DNA to understand the genetic risk of autism and understand how genes influence the behaviors that we see everyday. You know, for me as a clinician and as a researcher and for people that see them in the classroom or in your home. And then sort of how it may relate to future treatments and potential.

And then I want to sort of jump into some very specific contentairs of talking about genetic and brain findings that have occurred within, you know, brain areas that are responsible for social information. And then talking again about sort of what I like to call the carbs of autism, which is cognition, attention, and repetitive behaviors.

And then I'll just sort of follow up with some ideas and implications of what we're hoping we'll find in the future in terms of treatment.

So, why do we even care about genes in autism? How does this even help us? So, this is a model that's being used by many researchers, and this is often sort of referred to as bench-to-bedside research. And the idea is that you have a neurodevelopmental disorder that you really care about that you want to help families, you know, cope with the difficulties and help their children sort of achieve their best.

And then here you have the idea that if we do genetic work we can discover a gene. This gene can then be sort of tested in animal models which, you know, then sort of gives us some idea about the basic neurobiology. We can look at -- we can very closely manipulate DNA and protein and see how that then affects brain development, how it affects the wiring of the brain, what specific behaviors come out of that. Because we can control the environment so well and we can control the genetics so well in mice. That's

usually our default, although a lot of times some people will also use rats, mecaks or zebrafish or a lot of other animals. And then once we understand this basic neurobiology it sort of helps to confirm what is sort of the physiology? What is the brain aspect that's different? And then from that we can sort of begin to develop or identify new investigational drugs and new drug development, which then goes into novel treatments that are sort of targeting very specific aspects of brain development or brain function.

And so, this is sort of the idea. It's sort of like, you know, instead of just throwing down an atom bomb -- you know, not that that's what medication is doing -- but sort of hitting a lot of neurotransmitter systems that may improve some things but also make some things harder which, as we know, medications, particularly in kids with autism, while they can be very effective there can also be side effects. The idea is to limit that by making more targeted medications. And then that really helps, sort of, the children that are growing up and hopefully, you know, gaining more and more skills and sort of achieving their personal best.

So, this is sort of a model that we all use. And, you know, researchers that we work with across developmental neuroscience, psychology, psychiatry, genetics. We're all sort of working in this together because no one scientist can do all this by themself. There's just too much knowledge to know.

So, one disorder that's been studied a lot within autism has been Fragile X Syndrome. And this is sort of a disorder that we know, at this point, is a disorder of synaptic plasticity. And right now, it's the most common inherited form of an intellectual disability. About one third of individuals with Fragile X have an autism spectrum disorder. Now, if you go and look at all the kids on an autism spectrum disorder, very few of them have Fragile X. Only about one to two percent. The amazing thing though is that this is the most -- the highest like identified genetic disorder that can lead to autism that we know. There are others. You know, there's Velocardiofacial Syndrome, which is also known as 22Q. Anyway, there's lots of them. Smith-Lemli-Opitz.

But what we know is -- and what's really sort of helpful when we work with kids with Fragile X is that we know exactly where the genetic disorder is coming from. It's caused by an abnormal repeat of a very specific section of the X chromosome. And so, this is really helpful because we know that males only have one X chromosome, so if the mother is a carrier of this particular abnormal repeat then the child has the disorder. And so, we see it very present in males. Females are much more protected. And so, if they do have the Fragile X gene they may not show any symptoms at all.

Genetically speaking, women are much heartier than men. So, you know, and what's really interesting is that the results -- what happens is when there is this abnormal repeat, as it gets higher and higher, once it hits a certain threshold, it results in a reduced production of a particular protein. Which I won't go into details. But it sort of makes less of a protein and then that leads to the -- sort of the Fragile X disorder. And we'll talk a little bit more about this. And again, I'm trying to keep this at the high level because, you know, there's just a level where it's just very confusing to follow. But even -- definitely for me.

So here, under Fragile X Syndrome, here's sort of, you know, the X chromosome and here you can see this is the Fragile X and then this is a normal chromosome. You can sort of see it's fragile because it's almost like it's broken off here. There's these extra piece.

And then here you have a male where he's got his X chromosome and then here's your Y. And so, you know, this is why the disorder gets expressed. Down here is just an image of

two men who have Fragile X. And as you can see, as young children, you can see the eyes are slightly farther apart. You can see that their nose is a little bit wider. And you can see that the ears are slightly protruding. But as they become adults these features become very accentuated. The nose really sort of -- and the face becomes quite long and the ears protrude quite a bit. And then they also have macroorchidism as well in males.

So, these are sort of the defining features. And these individuals often have very impaired cognitive functioning. They have a lot of language problems. So, this is a disorder that clearly deserves a lot of study. And so, this sort of Fragile X, you know, this is protein acts as a break on neuronal activity. So, it sort of slows down brain activity. So, when it's not functioning properly brain activity is sort of too excitatory. It's not sort of in a good balance. There's sort of like too much activity.

And so, what happens is, in terms of brain growth, the dendritic spines grow very long and they grow very thin and they also have greater spine density. And you can see here this WT stands for the wild-type. So, this is a mouse without Fragile X, and you can sort of see here that there's sort of -- you know, the neurons are sort of branching out quite nicely here. And then here in the knockout mouse, that's why it's KO, this is a mouse that has Fragile X. You can see that sort of it's a very thin dendritic spine, and then they're also much longer. They sort of branch out very heavy. And sort of it's like bush-like. And this leads to a lot more problems and it leads to a lot more brain activity and sort of upsets the balance of activity and inhibition in the brain. So, there's just a lot of -- too much brain activity.

And so, when this happens, this sort of reduced breaking, it sort of leads to a form of synaptic learning that's disrupted. So, the way neurons learn and the way we all learn is that when neurons start firing together, they sort of are getting a better connection with each other. It's sort of a very basic neuroscience principle that we refer to as the Hebb Principle, where neurons that wire together -- sorry, neurons that fire together wire together. So now, what you have is if you have too many neurons firing and they're not actually related to the process that's important you have too much connection going on and you just end up with like this more disorganized signal rather than a very coherent signal that's firing like when you're listening to words and you're trying to come up with the meaning.

So, it just makes learning very disrupted and very hard to do. And so, it really leads to a lot -- we believe it leads to a lot of the problems in the cognitive and behavioral functioning of kids with Fragile X.

So, and one of the reasons -- I probably should have said this at the beginning, but one of the reasons that we're very interested in studying a disorder like Fragile X is because we know the exact mutation -- I keep doing that -- because we know the exact mutation in genetics it sort of takes out a lot of the guessing work. So, when we work with kids that have autism without a known genetic mutation, we're sort of -- you know, the genetic work on that one is very hard. It's like finding the needle in the haystack. However, when you know exactly what the genetic mutation is you have a lot greater understanding of exactly what's going on, what's being coded in terms of the proteins, and then you can sort of follow them through brain development much more carefully. So, that's why we want to sort of examine Fragile X and then examine the kids with Fragile X that then develop autism. That's a really important thing I should have said early on. But that's why we sort of really care about working with these kids from the autism's perspective.

So, there is ongoing genetics work. And, you know, there's this gene that has sort of been identified and it's sort of referred to as mGluR. Glutamate is a excitatory neurotransmitter. So, it sort of becomes active as neurons become active. There's a lot of glutamate in sort of the synapsis between neurons. And so, this -- what's really quite interesting is when we look at mice, if they're the wild-type, we sort of see that they have like a, you know, some amount of protein of, you know, of this mGluR that sort of helps to process the glutamate. And if you have Fragile X Syndrome you end up having, you know, too much of this protein going on and you end up with Fragile X.

If you have too little of it, which is a different type of genetic mutation, we actually see that kids develop -- or the mice develop brain patterns that look like Tubular Sclerosis, which is another genetic disorder that also has a very high rate of autism. So, what we're starting to understand is it's not like all or none, it's really about a dynamic balance. And if you're in a certain range that's a good thing. So, you know, this is sort of the typical range. And if you go too far forward you end up with Fragile X and if you go too far back then you end up with Tubular Sclerosis. And both of these have some overlap with autism.

So, that's a, you know, very interesting finding that came across. And again, it also leads to kids that have, you know, higher rates of autism as well.

What's really exciting is that in the past, I would say 12 months, 18 months, there's been some really amazing literature showing that a particular medication that sort of produces the missing protein from Fragile X has actually recovered these animals. And when I say recovered, I mean we started giving them this medication and their brain cells, which will look like this, then start to look like this. Literally changing the cell structure. That's incredible. I think it's incredible.

So, and the other thing that's been really exciting from, you know, from people that I work with at CHOP, is that we've also found that this particular genetic mutation here, that when you see it sort of being manipulated we also see it's involved in reinforcement and reward learning. And there's a lot of literature coming out right now in autism suggesting that autism is really a disorder of learning. And in particular what people think, is that, you know, we get a lot of our information, particularly at very early ages in life, from the social environment. Nobody sits down and tells you look at your mom in the eye, look at this, look at that, pay attention to these words, this is how you learn how to speak. They pick them up implicitly, why? Because they know or they -- kids typically will follow someone that's a speaker or will follow a person.

If you're in a room with a child, just a regular old kitchen, you might take up what? Five percent of that total space in that room, right? There's a hundred square feet, there's lots of objects on the wall, if you're sitting in the kitchen with your child. But that child will probably spend 98-99 percent of its time looking at you as a person because you're interesting and important and you're rewarding to them. And it's exciting and when you smile at them that sort of really gives activity to areas that are involved in reward.

And so, the fact that we're starting to see that this may also be involved in reinforcement learning is also really interesting because what we're trying from the treatment side is, we're trying to see can we influence the -- sort of that innate social reward? Can we increase that in kids with autism? Will that help them get more information out of the social environment?

So, that's sort of one thing that's really exciting is that not only do we see that we can recover at the brain level, but we also see that for areas that we have seen behaviorally

that we've been working on for years, I mean, ABA is built on reward and learning. Right? And so -- and one of the hardest things, if you work with kids doing ABA work, is that if they're not motivated to actually interact with you, you have to spend months to years just working to get that motivation, just working to get them interested in you. And then move on to actually teaching them the skills you want them to learn. So, if you can sort of jump that hoop right there and sort of have them already interested in you, that's a huge hurdle to overcome. So, this is why this is really exciting for us.

So, this is just a schematic of the genetic piece I was describing. And really -- so, like I was saying here. Here is the glutamate receptor gene that sort of affects the translation of this particular protein. And this is what's disrupted in Fragile X. And it's sort of, you know, positive. It's going way too much in Fragile X. And this protein that's missing, this is what's supposed to put the brake on it. So now, what we're doing and what we've done is there are drugs that block or down-regulate this and they're reversing the symptoms of Fragile X in the animal models, like I said. The cell structures are normalizing. They're starting to learn better. This is ground-breaking research.

Learning problems are reduced, seizures go away, the abnormal dendrites, they all go away. This is exciting.

So again, you know, coming back to what I started with saying that Fragile X is a syndrome that affects synaptic connections, and there is a lot of evidence out there also suggesting -- and we'll talk more about the genes that are involved in autism a little bit -- they're also affecting how neurons connect to each other. And that this breakdown is what we're seeing as being most related at the genetic level and at the brain level. And so, if we can improve that, if we can enhance that, we can enhance learning, we can then enhance outcomes. That's really our goal.

So again, coming back to this model, right. So, why did we care about this? Well, we started from a disorder like Fragile X and autism. We've gone through the gene discovery into the basic neurobiology, which helped us understand the path of physiology with the cell types. And there, you know, a drug was identified and was applied in the animal model. And so, it was really quite successful. So now, there are now drugs that have been developed and there is a human clinical trial that's beginning now. It's called arbaclofen, is the name of the drug. It's actually a drug that's been around for a long time. We've known that it can sort of produce this particular protein that's missing, but it's never been used before. It's only being started right now. So, this is really a quite exciting time to sort of see this research go on.

So, now there's other types of genetic studies that are done, and this is sort of more focusing on kids with autism but not a known genetic disorder. Which is the majority of the kids that we see. And so, there are two types of genetic risk factors that one can have. One is a common genetic risk, and this is found throughout the population. Like people have natural variation. That's why we can sort of, you know, continue the species is that there's always these little changes that go on. And, you know, it can be 50/50 in the population. It could be 80/20. But these little differences allow us to sort of continue to propagate in the population. And so that, you know, that's why we're all different and leads to different types of advantages evolutionarily and biologically. And some of these will confer a very small amount of risk since they're in the common population. I think about them as being like turning up the volume. So, like, if there is something going on it sort of adds a little bit of risk. So, it's like if you have one of them maybe it adds like .5 percent risk. But if you have a hundred of them then it might add to like 25 percent risk. And that's just an example.

Then there are these rare gene mutations or rare gene factors, and these confer a lot of risk, but they're really not found in a lot of people. Like less than one percent of the population has these. So, you may have to go out and screen 7,000-8,000 children with autism to find 20 kids that have this rare gene mutation.

And so, again, so what this has sort of contributed to in our understanding right now is that we think that really what goes on is that each person with autism has a combination of the common genes that have a little risk and then the rare risk factors that have a lot of risk. And so, you start to get these groupings. So, you might see that person one has sort of C1, C5, and C12. Person two has -- and this is just chromosome 4 -- I mean chromosome 1. It's just an example of a gene. And chromosome 4 and then 5, 12, and then R7. And so, the argument here would be look, these are like big risk genes. These might five percent risk by themself. But then these are the common ones, they're very little but they'll be in a lot of kids. And so, this combination together will give rise to a child with autism. And this will give -- a combination will give rise to a child that will have autism, but these children will look somewhat different because they have different genetic risk factors.

And I think that's really -- for me, it strikes home of well, this makes sense. Because we often joke, at least clinically, if you've seen one kid with autism you've seen one kid with autism. Like you really don't know what autism looks like from seeing 1, 5, or 10 kids. You have to see hundreds to really get a good feel of how -- the breadth of the autism spectrum.

And so, this really makes sense to me because it means oh, we can find subgroups. Groups of kids, if we look large enough, we can see that there are these subgroups of kids that sort of go together. Their language is on time, but they're really sort of odd in the way they interact or start conversations. But they will come up and start conversations with you. And that's very different from the child that maybe, you know, doesn’t learn to speak until they're eight or nine years of age.

So, this is sort of -- you know, this sort of intuitively makes sense from a clinical perspective.

So, what we're hoping is that sorting by these risk profiles, that that will bring increased clarity to understanding autism. So, just as I was saying, right now we have this whole group that we call Autism Spectrum Disorder which really, honestly, is because we don’t have a better way of subdividing these kids right now to being, you know, better, clearer groups. And what we know is that they’re really going to start to subtype them based on these shared risk factors. And so, these kids are more alike, and this kid is more like this kid. And then what ends up happening is we'll start to group them in kids that really should be grouped together. And then that allows us to actually identify to the best treatments. So, if we have -- here's eight treatments that work for kids with autism, but we know if you have this particular genetic makeup or maybe, you know, gene by environment if we understand the environmental factors that play a role, then we know that they'll respond best to treatments one and four. And this kid, well, they will respond best to treatments two, three, and four. But this kid really only responds to treatment four.

So, that's just something we're sort of thinking about of how genes can sort of play a role in what we do.

So anyway. Some genetic findings that have been exciting. So, at CHOP, of course I have to talk about work from our lab, or our center I should say. There was, you know, the first

sort of common risk gene that was identified. This was just a couple years ago. Some of you may have heard of this before. But it's really about this cadherin region right here on chromosome 5. And what cadherin does is it regulates a calcium channel. And the calcium channels are channels that help to regulate activity between two neurons, between, you know, an axon and a presynaptic terminal. Or a dendrite and a terminal.

So, when this gene is sort of disrupted it sort of leads to a breakdown in how those two connect to each other. And so, this was the most common variant, and they believe it explained up to 15 percent of idiopathic autism. So, for kids that we don’t have an identified gene like Fragile X, we believe that this plays a role in up to 15 percent of cases. Previously we had never identified a gene that had accounted up to one percent other than something like Fragile X. So, this was sort of a landmark finding.

So anyway, as I was saying. The cell adhesion molecules that are important for setting the correct balance. Like I said before, there's this dynamic of excitation and inhibitory transmission in the brain. It's really important for synapse formation and maintenance, as I explained before with like the Hebbian Principle of neurons firing together, wiring together. So, it affects learning and it affects how the neurons sort of go out in the brain and then connect across different brain regions. So, clearly these molecules are playing a very big role.

There's also another set of rare variants. These are the ones that occur in about one percent of the population, and these tend to implicate biological pathways that also regulate what's going on at the synapse, at the level of two neurons connecting to each other. And these are often referred to as ubiquitins is one pathway that's been talked about a lot, and these are enzymes that degrade synaptic connections. And they degrade proteins that are at the synapse. So again, we're talking about things that regulate connection from one neuron to another, one brain region to another. This is where the breakdown is occurring, this is where we're finding the most bang for our buck right now. And so, this is where we really want to target going forward.

So, here when we look at areas of the brain that are implicated, when we looked at sort of this cadherin 10, this sort of cell adhesion molecule, we saw that the brain region, that it was really expressed in adults were brain regions that we really care about in autism. Brain regions we've been studying with neuroimaging for years, including the amygdala which is really important for emotion. Including the substantia nigra, which is really important for releasing dopamine that sort of helps us learn. And then also the temporal lobe which is where there's a lot of processing of social information like biological motion, like my arms moving and other types of social tasks.

So, this was really exciting because it felt like from this other field we were getting all this conversions from work that we'd been doing for 15 or 20 years. And sort of saying yes, this is what's going on. It is about connectivity. It is happening in these brain regions. So, this was really exciting for us as well.

So now, I just want to -- so, done with sort of general genetics. I want to take it into sort of very specific types of behaviors that we might see or difficulties that we see either in the lab or in the classroom. So, we'll start with talking about the social brain. So, what is the social brain? It's a collection of brain regions that are connected by, you know, long range white matter tracts. And so, the key areas -- so, in terms of understanding environmental threat or tagging a particular stimulus in our environment with some form of tag, like it's friendly or if it's a threat or, you know, this is a positive moment, this is a negative

moment. That's what the amygdala's doing and that's here in red. It's sort of buried inside the medial temporal lobe.

For perception. So, if we're looking at faces and for looking at biological motion, looking at expression. Seeing, you know, what is the intent of this person? They're reaching for something. Are they reaching for the glass? Are they reaching for a fork? You know, that is what this is about. And that's the purple regions over here.

Here in terms of outcome expectations, so when you're sort of trying to make a judgement about okay, I've seen this stimulus. And look, it's a furry animal. Is it a dog or is it the tiger? The outcome expectation that you would attribute to those, again, is processed by regions in the amygdala, processed by regions in the basal ganglia, as well as some somatosensory like if you're thinking about motor planning like fight or flight kinds of responses.

And then, in terms of what you want to do about it are these brain regions here in blue. The orbitofrontal and the ventromedial prefrontal cortex. So, this is sort of just the social brain.

And so, what does the social brain do? The social brain allows us to understand and attribute meaning to events that potentially have no meaning. And just as an example, I'm going to show you this video.

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So, that's a little cartoon that we would show to kids. I see a few smiles. And if I were to ask kids, you know, to describe that a lot of the people might say well, the little triangle's teasing the big triangle. You know, making fun of him. This is an example, right? What did you actually watch? You watched two triangles moving around on the screen. But it's very easy to sort of attribute a meaning, you know, sort of anthropomorphize these triangles into having an intention, having a goal, having a sense of humor. And that is part of what the social brain does. It allows us to make those sorts of predictions and think about those things. And those are the types of skills that can be very difficult for kids with autism to get intuitively. They can learn them. A lot of treatments work on these types of skills. And that's great. That's what we, you know, we want to sort of help kids navigate the world. But that's what the social brain does.

And one gene that's sort of been related to this -- there are many genes -- so, one gene that there's been a lot of talk about is a gene that is sort of affectionately known as CATNAP2. Somehow that n became an a. But we call it CATNAP2. And it, again, it encodes a particular protein that is at the node of ranvier. And the node of ranvier is the part of the neuron where it sort of like recharges to keep sending a signal. So, you sort of have like the axon and the signal comes down it, and then you have a node of ranvier and it sort of like recharges it. It's like a little generator to keep the signal going. And this particular channel, this is where this protein works and there are a ton. All of these that are in red, these are deletions or duplications or manipulations that have all been related to autism within this one CATNAP gene. So, there's been a lot of evidence to indicate -- not just autism, it's also -- these other ones have been implicated in language impairment and language difficulties.

So, it's related in general to sort of language development. But what's interesting is people have also followed a particular snip here which is a common variant. And it's about a 50/50 split in the population. So, it makes it really easy to study. And so, if someone wanted to look at well, how does this relate to brain function? So, one thing that we do

when we measure brain function is we do something called functional connectivity, which is really nothing more than thinking of the brain and brain regions that work together as a network as being synchronized swimmers. So, if you have two brain regions, like Broca's and Wernicke's, which are important for language production and language, you know, understanding. You know, their activity, as you can see here in a control participant, their activity goes up and down together quite nicely. They're sort of really coupled. As synchronized swimmers they're pretty good.

And here in an individual with autism we can see that there's much more separation. That they're not going up and down together. This is sort of what we term functional connectivity. Gives us some sense of how well connected the brain regions are across time. And that's what this is. This is just how many brain images we take across time.

And so, this gives us some sense of how synchronized, how efficient they are. That's sort of what the goal is there.

So, if someone said okay, well I am going to look at, you know, this particular brain region. This is the medial prefrontal cortex. This is really important for things like understanding theory of mind, like that little cartoon I showed you. And here is -- we would then want to see it in kids with autism and kids without autism. And ultimately what we ended up finding is that the gene was stronger than groups. That there were no group differences, but when you collapse across and just looked at the risk gene, like did they have the risk gene, or did they not have the risk gene? We started to see findings that looked very common in autism studies. Which is we see that when kids do not have the risk gene, they have much better long-range connections. But when they do have the risk gene, they actually have better short-range connections.

And so, that's really striking because that's what we've seen in a lot of our sort of postmortem research is that sort of connections locally are really strong, like I showed you with the Fragile X. Like these really dense bushes that are connecting lots of neurons. But in the long-range they're not connecting so well.

And so, this sort of seemed to mimic that. So again, this was really quite exciting. It's again, converging with all this other evidence we're seeing that genes that are important for connecting neurons, they're having breakdowns and they're leading to the types of learning impairments and leading to problems in the brain regions that we see as often being --developing atypically in autism or functioning atypically in autism. So, that's really sort of exciting work.

Another study that came out looking at just, you know, straight brain structure and volume. So, we know from a lot of -- you know, probably now since the late-80s, early-90s, that there's atypical brain development in the frontal lobe, the temporal lobe, the amygdala, and the fusiform gyrus. Which is really important for face identification in kids with autism. And there was this nice study about maybe two years ago where they looked at very young kids, kids who were about one-and-a-half to four years of age, and they -- we looked at their relationship of their brain development to the serotonin transporter gene, which is a gene that basically -- you know, when you have serotonin in your synapse it clears it out. It sort of like resets the synapse so it can fire again.

And, you know, since the 1960's we've known that about one in four kids with autism have too much serotonin in their blood. And so, this has long been a hypothesis. So, someone wanted to look at that. And so, basically this goes from like low, medium -- I'm sorry, low autism risk, medium autism risk, high autism risk. And as you can see, this sort of relates

to the volume of the frontal lobe. You can see that the frontal lobe gets bigger as they have more autism risk genes.

And that, again, is really interesting converging evidence.

What's also interesting and, you know, people tend to focus a lot more on the younger, early school age or preschool age. There's also been some really nice work -- this is out of a group from NIH -- where they looked at like, you know, for brain imaging research a large sample of 40 adolescents and they actually found that in adolescents that there was sort of this arrested growth in adolescence. So, we talk about this early overgrowth in sort of the early school age, between like, you know, one-and-a-half and four years of age, that there's a lot of fast overgrowth and kids get, you know, bigger head sizes. But by the time we reach adolescence those differences in head size tend to go away. And now what we actually see with brain imaging is that this is also related to sort of like -- sort of a very quick development in sort of particular regions important for a social brain like the inferior temporal and the superior temporal sulcus.

And so, it's sort of like a second hit or a double dose of changes in the brain. And there's a lot of interest from this group to continue to look at this to see are there other genes? Because genes can get turned on or turned off across time. This is a whole field known as epigenetics. And so, people really want to understand is this something that's happening as kids get some experience? Or is this something that is sort of set very early on? So, there's a lot of work, so they're trying to pursue this finding much more.

So, this next area is to look at the carbs. So here, you know, just to describe what are repetitive behaviors, I think a lot of people think of repetitive behaviors as just being something as simple as hand flapping, which is one of the more common, one of the most visible signs that we've seen in autism. It's certain ones that we see displayed in the media. But really there's a much broader set of symptoms that this comprises, including self-injury. Which a lot of kids will do headbanging. I worked with kids who had Down's Syndrome and autism and they had repetitive thumb sucking to the point where the nail was gone and they started to degrade the skin in their thumb. And, I mean, that also counts as a significant repetitive behavior.

Whole body movements including jumping and spinning. As well as repetitive sensory seeking. So, licking, rubbing things, smelling things. This is sort of what we'd consider lower order. And these particular behaviors we see in kids with autism but we see in kids with a lot of other developmental disorders as well.

In terms of the higher order behaviors, these are ones that we see mostly in autism. There's a few other disorders that show them, but mostly it's autism. And this is things like difficulty with transitions. Right? You know, if the schedule gets changed in the day you get a meltdown. If you change something simple in the environment, like you move a couch over, or instead of having a blue cup you give them a red cup to drink from they get very upset. This collection of behaviors we often refer to as being an insistence on sameness.

And then finally, the other area which we think of a lot as well is the restrictive or circumscribed interest. And this can either be an interest that is typical for an age. So, if you have an eight-year-old that really digs "SpongeBob" that’s not so weird. But if that interest is so intense that the child cannot speak about anything else, that it interferes with any other part of the day and that they would just sit and watch all day long, that would be sort of a circumscribed interest. That would be too intense.

Or it can be atypical. Right? You know, you can also have -- so, just as an example, like here, you know, common interests. It can also be an atypical interest and I worked with one child who was obsessed with toilet bowls. And so, one of our key therapy goals in working together and talking together was how could he go into a building and not go look at every toilet bowl in the building to see what model it was and who made it? That he had to do that. And every person he met, that was his first question is, what is your toilet bowl? What model is it? What year was it made? That's what he wanted to know. So, that would be another example of an atypical interest.

So, you know, to look at the behavior piece of this, Dr. Laura Anthony, who I worked with when I was in Washington, D.C., we sort of -- a group of us looked at sort of this interest checklist that's sort of been developed. And it isn't made yet for clinical usage. It's very new. And so, it gives about 41 different interests and parents say is it current or is it ever? And it's all different categories. Categories you would think kids with autism would be really interested in like numbers and numerical information. But also interests just for typical, you know, like typical kids get really excited about including sports, people, music, videogames. Just the whole gamut of types of interest.

And then the second section is the intensity rating. So, we asked parents, it was open ended questions of what are the top three interests? And we have -- there was eight questions about the intensity or the interference. How much does it get in the way? Do you only talk about that with other people? You know, and sort of getting parents to do ratings on that.

And, you know, our thought was okay, well, when we do this type of work what we expect is that kids with autism will have fewer interests overall, because it's supposed to be restricted, and they'll be much more intense. And what was really interesting for us -- first off, I can just sort of say this, is that what really separated the groups was the intensity of interest. So, when we look at how much kids with autism like their interests, that intensity was much more severe and much more intense than typically developing groups.

And this is a study of kids ages 6-17. And we found that the number of interests didn’t discriminate at all. That actually that they had the same number of things that they were interested in currently and also across their lifetime, which was kind of surprising to what we thought.

What's interesting though, is if you then look a little deeper and see just qualitatively, what are the things the kids are actually interested in, if you look at the males I think it's interesting to see that males kind of have some overlap. You know, both have an interest in videogames is in the top three. And if you look at the girls there's no overlap whatsoever. That the girls are really different. And understanding what happens with girls with autism is a real high priority, not only in our center but across the country because generally speaking the incidence rate is so low. We just don’t understand what's going on as well as we do in males. So, there's a big push to try to understand more about development specifically to girls with autism.

So, when we think about the repetitive behaviors, you know, there's been some really interesting work coming out sort of talking about that there are -- may actually be -- we used to talk about repetitive behaviors as being one big category. Like making no distinction between an obsession about John Lennon and flapping your hands. That that was one big domain. But in reality they're very different. And so, recently there's been some nice work sort of trying to understand and to think about them from a theoretical

perspective, that these behaviors -- and they're not just in autism. There are all sorts of repetitive behaviors.

So, like, the hand flapping and motor loops people have started to think about them as being related to, you know, one particular neurocircuit in the brain. And we see -- you would see atypical development or function of this, not only in autism, but also in Tourette's Disorder and also in Parkinson's. And so, that they sort of have these same kinds of repetitive behaviors. That they look very similar, even though the disorders are very different and obviously at different time points in your life.

This middle loop, which is called the associative loop, this we see involved in a lot of disorders that have problems with impulsivity or rigidity. So, this loop, you know, we see being disrupted at the brain level in kids with OCD. They're incredibly rigid as well as kids with autism. And then the impulsivity piece is also what we see a lot in kids with ADHD. And so, this has sort of been thought about as being a separate loop.

And so, the idea is that we're trying to load these different symptoms of autism onto very specific neurocircuits. And the idea is that we can load each one onto a different circuit then we can sort of look for that and test for that particular circuit. And there are different genes that may be involved and different types of treatments that you may want to pursue for each of these different circuits.

The third one, which I'll just say real quickly, is the one we think is related to obsessions and compulsions and in restricted interest. And this is a network that we see as being very much implicated in reward. So, we see this as being disrupted in kids with autism when we show them pictures of people smiling at them. As like, you know, as a reward for doing a good job. And we also see -- you also see a really -- actually, a lot of hyperactivity in this particular loop when you work with drug addicts and you show them pictures of drugs.

And so, there's some thought -- some people, you know, in that literature, people talk about something called reward toxicity, which is the drug becomes so much more pleasurable. Cocaine influences your dopamine so much and is so pleasurable that the gradations between other things you might find rewarding, someone giving you a hug, falling in love, earning money, it all pales in comparison to the reward of the drug. And so, some people -- and this is something that I'm pursuing with people at CHOP -- we're saying well, maybe this is what's happens in some kids with autism, that the restricted interest becomes so rewarding everything else just fades away. And so, we want to sort of pursue that. And we think that this might actually be opposite of, you know, if you're really interested in sort of these -- you know, something like toilet bowls or trains, you may be less interested in people. They may not hold the same weight. And so that those things may be opposite balance to each other. So, we're going to try to sort of look at that. And I just want to be clear, our goal is not to take away kids' interest or love of those things, but to understand sort of the dynamic and the balance of what's going on in the brain.

So, we'll focus a little bit here on this loop that's related to the need for seeing this. We looked at that same gene as I described before, the CATNAP2, which influences connectivity. And this is from research that I've done with people in Washington, D.C., that were -- we haven't published yet, but here we sort of have like the low risk, the intermediate risk, and the high risk kids. And this is a scale of sort of flexibility or shifting. And it's -- for those of you that are teachers or maybe parents, you've filled this out before. This is a measure of executive function called the BRIEF and it has a scale about flexibility and asks questions like does your child transition well from one activity to

another? Can they alter their problems if -- you know, can they alter their solutions and come up with a new idea if they get stuck on something?

So, really trying to get at different types of being flexible. And we can see that the scores here are much higher between here and then the low risk, that this is different. And this is work that we're continuing to pursue right now. Because this is a small sample. It's only about, you know, 50 kids and ideally you probably want 3,000-4,000. But we're working with the Simons Foundation and looking at this a little bit further in their sample, which has about 2,500 kids. So, we'll hope to have more research on that soon.

So here, just to talk a little bit about CATNAP2, I just wanted to summarize it since I talked about it twice. You know, it influences these channels that play a role in neuron-to-neuron connectivity. And it's clearly related to poor synchrony of brain regions, as I discussed earlier, that process social information. And it also -- the presence of these risk alleles also seems to relate to more levels of rigid behavior. So, it seems like it really is playing quite a large role in autism. Or at least, we're hoping it plays a large role, and large meaning, you know, maybe a half to one percent.

One of the last big areas I'll talk about is I wanted to talk about attention. Because this is an area that I'm really excited about is trying to understand attention or ADHD symptoms in kids with autism. We see it in them a lot. And until -- in the current DSM you're actually not allowed to diagnose ADHD in autism. But in the new one they're actually going to allow you to diagnose both together. And that's had a tremendous number of treatment implications because some people will not use certain treatments that could be helpful, because they say well, it's not really ADHD, it's autism. So, that's not always helpful.

So anyway. As you can see up here these are, you know, about 30 percent of kids with autism would meet ADHD criteria. About 25 percent more will exhibit some symptoms, but they don’t sort of meet the full criteria. And overall these kids that have both, symptoms of both, they actually have worse outcomes. So, they have a harder time sort of doing day-to-day skills. They're more disorganized. They really do struggle quite a bit. And what's interesting is when we use sort of our classic ADHD medications, what we understand right now is that it is successful for about 50 percent of kids, but that's a really big drop off from 90 percent that we see in kids with just ADHD alone that respond to Ritalin.

And in kids with Ritalin, we might see somewhere between one to two percent of kids having a side effect. In autism it's almost 20 percent. So, it's a tenfold increase of side effects. That's really suggesting that there may be a different type of pathophysiology. But that there is also some amount of overlap.

So, in terms of the genetic side of this, there is some encouraging evidence that we need to pursue autism in ADHD genes. In particular, there are 16 genes that we've -- had identified in ADHD that are also very close to regions that we've recently been thinking about for autism. And when we look at the autism risk genes, which there are many more -- there's probably been, you know, about 300 genes implicated in autism if you were to go through every single study -- there's about 25 of them that have also been shown linkage near ADHD risk genes.

And, you know, right now, as I mentioned earlier, you know, one of the big problems we have is that you need thousands of people to make these studies work. I mean, we thought if we got to 2,000 or 3,000 people that we would be in a good position to really understand autism genetics, but now based on sort of a recent -- there's a recent sort of grouping together of all the big geneticists in the world and they were presenting all their

findings and they sort of felt that at this point, you know, having several hundred of, like, really sort of kids that are genotyped at a very deep level is not enough.

And, you know, even doing sort of these faster screenings where they genotype, you know, everything in sort of bigger chunks -- I mean, they have, like, you know -- they have, like, maybe 5,000-7,000 on those kids, that's not even enough. They're actually now looking and gearing up to try to get to 10,000-20,000 people. Just to understand what's going on at the genetic level because so many of these genes are conferring risk that's under one percent. So, that's really a major issue.

So, one thing -- so again, so looking at the overlap, is there overlap at the brain level? This is a study out of the Netherlands. And one of the things that they did is they looked at kids with autism, kids with ADHD, and then typically developing kids. And what's real interesting here is they wanted to say well, are there brain regions that they're -- differ? You know, that are similar? So, what's the overlap at the brain level?

So here, you know, you can see that autism and ADHD -- sorry, and this is one is very specific to autism. This is a region part of the superior temporal sulcus. This is part of the social brain. This is important for, you know, attention and biological motion processing. All these social types of abilities. And this was unique to autism.

In B, we have a region that's common to both and this is in the inferior parietal area, which I showed you earlier in the imaging and I said that that was related to sustained attention. And so, this was an area where there was, again, sort of increased gray matter. There's too much gray matter there. Too many neurons would be sort of the argument.

And again, this is an area of overlap and this makes sense as we see problems with sustained attention in both kids with ADHD and kids with autism.

And then finally in C, this was an area that was reduced in both groups and this is an area related to memory and emotional tagging. And again, that's also not uncommon as there are memory, you know, memory problems in both groups of kids. And then in this case there actually happen to be less gray matter. So that you're getting -- again, in brain development and brain function we don't always necessarily see that there's reduced activity or there's just increased activity or the brain's too small, the brain's too big. A lot of times it's a balance. Some regions are bigger and some regions are smaller.

What do kids with autism and ADHD look like relative to kids without autism and ADHD? And what you can see here is -- this is a really great graph to describe because it's really step-wise -- these were our typically developing kids. These were our kids that have autism but very few ADHD symptoms. And these were kids that had really severe ADHD symptoms. And you can just see -- this is, again, this is the BRIEF, and this is sort of like an everyday measure of executive function. So, we'll ask things for inhibition, we'll ask does your child blurt out? For things like working memory we'll say, does a child remember how to do a two-step direction? For things like flexibility it'll be things like, can your child transition from one activity to another, even if both activities are enjoyable?

So, it's really giving us a sense of, like, these different types of cognitive skills. And we can see that the kids that have both autism and ADHD are being rated as most impaired by their parents. And it's just across the board. There's no specificity to like one domain.

We then wanted to look at adaptive behavior, which is a measure of your day-to-day skills. So, this is like, you know, the communication domain is, does the child know 10 words? Does the child know how to write letters? This is very different from the

communication symptoms we often look at with something like the A-DOS or that we'll do with parent interviews. Because there we're looking for atypical language. We'll look for things like, does your child does stereotyped or repeat phrases over and over again? Do they do echolalia? Which is very different. It's sort of almost like you're looking at the negative symptoms. You know? Sort of things that are really atypical. And this is how much things do you do in your day-to-day life? How much do you use language? How often do you sort of, you know, read and write and how much do you understand? Can you listen to a story for five minutes? We don’t capture those things with the diagnostic instruments.

And so, here what you can see, which is quite interesting, is for communication abilities and here in social abilities, there's really no difference. I mean, the group that has autism and ADHD -- lower scores is worse in this one because we're talking about positive skills. So, the higher the better you're doing. So, these are our typical kids again. And then our kids with autism and not ADHD symptoms are slightly higher in social and in communication skills. But these are actually not different from each other.

Where we saw a big difference was here in daily living skills. And this comprises things like, can you dress yourself? Can you feed yourself? Can you go into the community and understand how to get around? Can you understand stop signs? Can you understand how to clean up? You know, and this all -- I mean, this sort of makes sense because this takes a lot of planning and organization. I mean, to get up in the day, if you really think about it, like getting dressed when you're four, five, six, seven, eight, nine years old? You've got to think about the weather, you got to make sure you put on the underwear under the pants not over the pants. Right? I mean, there's all these little planning details. And the kids that have more attention problems probably will be more impaired in this area.

So, when we talk about these kids having worse outcomes, this is the type of thing we're looking at. That these skills, I mean, I think, as a clinician, I would say my experience is a child that is still in diapers when they're in school age is very hard for a lot of parents. And so, a child that can't do those types of activities like, you know, using the bathroom, toileting, feeding themself, those are the kinds of the behaviors that are really stressful on the family. And also sort of in the classroom as well. And so, this is really quite striking for me and clearly an area that needs to be targeted as we move forward in thinking about treatment implications for kids.

Finally, we looked at some maladaptive behaviors. And so, this is -- you know, here we have externalizing symptoms. This would be like acting aggressively or sort of what people often refer to as acting out. Internalizing symptoms which would be more like anxiety and depression types of symptoms. And then here we have hyperactivity, attention problems, atypicality which are sort of odd behaviors, you know, or someone being -- and then here we have sort of withdrawal or being withdrawn.

And so, here what you would expect is that, you know, kids with ADHD tend to score really high in externalizing symptoms. Kids with autism tend to score higher with internalizing symptoms because there's also, you know, pretty high levels of anxiety in kids with autism.

And then here's hyperactivity and attention problems. They should be high if kids have ADHD symptoms.

And then here the atypicality is something that we expect to see as being higher in kids with autism because it's odd behaviors. You know, kids engaging in compulsive behaviors or lining things up. Things like that.

And then, of course, the withdrawal you would expect to be high in kids with autism. And what's really quite striking for us is that the behaviors that seem to be more specific to autism, we don’t see much difference in parent rating. So, the internalizing symptoms don’t look that different. The withdrawal symptoms, there's being socially withdrawn, doesn't look that different.

The atypicality is sort of on the fringe there, but it's not different. I think it probably would come out if we had a few more kids in the study.

But where there's huge differences are in the externalizing symptoms. Kids being aggressive, not following directions, yelling. And then here, being hyperactive, blurting out, being impulsive, having a hard time staying on task. These kinds of things all came out as being different.

So, this was nice because it showed that it's really specific. It's not that parents who have kids with autism and ADHD symptoms just rate their kids worse on everything. You know? Because all the things I've shown you up to now, the kids with autism and ADHD symptoms are worse on everything. And it's not that these parents just feel like these kids are -- these are parents that have like maybe a bad view of a child where, like, they just think he's bad everything or she's bad at everything. It really is specific to certain behaviors. And so, that's really important to identify because you want to make sure that there's not just a bias, you know, a response bias to being more negative. So, that was really sort of encouraging there. But all of this is just to highlight sort of the outcomes, what we see as being harder for kids that have both disorders.

So, we're almost done. And so, what I'll do is I'll talk a little bit about treatment implications of all the findings. I'm going to try to make this brief. I have two slides. I have the near and far future.

So, the near future -- and this is my perspective for sure -- is that I think, you know, we're working very hard to do behavior screening within the first 36 months. Right now, it's for kids that we sort of perceive as being at high risk. I think we're probably going to continue to work on developing a profile of behaviors that can identify children at high risk. And I really -- when I think about this, I'm thinking about getting this into pediatrician offices. Because right now it's now a mandate to give sort of this little checklist that some of you may be familiar with. It's called the M-CHAT, the Modified Checklist for Autistic Toddlers. And it's great. It's a nice screening tool and it takes about 10 minutes to administer. But, you know, when you get about 15 minutes per patient for a well-visit as a pediatrician in an outpatient clinic you don’t want to spend 10 minutes just asking about autism symptoms when you've got to cover the whole gamut because the child may show signs of some other issue.

And so, I think the goal is to identify something simple that can be done in an office that can be sort of done maybe by a nurse or a technician and then can be consulted with a doctor and then turned over. You know, that would be the ideal, right? I mean, we've developed five-minute strep cultures. Hopefully in the future we can develop better five-minute measures to sort of get a sense of risk. That's what I think a lot of people are working on.

You know, there's a great research center in Atlanta run by Ami Klin who's doing this with babies and having them -- they have like this little eye tracker thing, and you put the baby -- so like, you put the baby inside like a little videogame box, they watch some things, they watch the baby's eyes, and then they are actually trying to chart well, how interested in social information is this baby? And their goal is if they can sort of do it like a growth chart, if you see the child's off the growth chart, then you can say this child's of high risk for autism.

I'm not sure if the test is going to get there, but this is the type of thing I think you're going to see a lot more of in the next three to five years. And I think this would be huge for us.

Other things that are important I think is once we identify certain types of behavior assays, I think it's going to be really important to validate that with brain imaging techniques like MRI or using EEG. A lot of people, I think, want to sell us on the idea. And I'm someone that uses a lot of imaging in my research. And a lot of people want to try to say that we're going to replace behavior testing and psychologists with neuroimaging. I don’t believe that's going to be the case. I think what's really going to happen is we're going to be able to come up with better behavior tests. Because a behavior test takes five minutes and that's a lot easier and a lot less cost, you know, costly than sending somebody up for a $3,000 clinical MRI that takes an hour and a lot of kids may not want to stay still for it.

So, I think it's better to say we're going to use the MRI to validate that this is a good behavior test. It's going after the brain regions we care about. We know it relates to the genes. That's what I think is really going to be the future of MRI.

And so, I think that's something, again, we're going to see over the next three to five years.

And I think using these biological markers, using the genotypes, using the neuroimaging markers, and even sort of things from the EEG, other type of electrophysiological signatures -- you know, we could also get things like skin conductance and heart rate, I think these will also help us understand, like, if you're reactive in certain ways, if you have a certain genotype, that may predict the treatment, you know, outcome. That you may do better with this treatment, you may have a better prognosis. And so, I think that's also something that's more likely to come in the next several years. At least there's a lot of research that's being funded to do this kind of work.

And I also think a lot of behavioral markers have been shown. So, right now we have two. One is if you have first words before age five, you know, that is one of the best predictors for a child having a good outcome as an adult. Along with sort of an IQ in the average range. And then I also want to -- you know, something that I'm particularly interested in is looking at the development of insistence on sameness behaviors because these present in young kids, even typical kids have these sort of needs. Like they want things just so, they'll line things up, they don’t want food touching. They have all these preferences. I don’t want to eat white things. You know, that happens. But, you know, what we're starting to see is that there is a -- sort of a point where that behavior, that trajectory, where typical kids are like that and then they get over it, I mean, kids with autism keep having problems and they become more severe. So, I think if we can map out that sort of growth trajectory that will also be something that's very helpful and something for the future as a potential behavioral marker for predicting outcome. Because these behaviors are extremely limiting for adults. I mean, so if you have a problem that you need to have things at a certain schedule it really gets in the way of adults with autism holding jobs, being able -- because that schedule can get disrupted and things don’t always go exactly the same.

And so, if that stops you from walking out the door that stops you from having a job, paying your bills, living independently. And that's really where we want everybody to get to. So, that's the goal. So, this is an area -- again, I'm very passionate about this area. I feel like the social brain is what we talk about a ton, and these behaviors sort of been lagged behind because generally they've been hard to explain. We don’t know why they go with social and communication problems, but they do. So, that's just my plug for research that I do.

In terms of the future, the far future, I think what we really would like to see is that genetic screening at birth or even before birth. You know, we can sometimes sort of obtain the genetic structure of the child through a placenta. But here, you know, we can sort of do a profile of genetic risk factors not only for autism, but for a variety of developmental disorders. And that we can have, you know, based on the risk of all these sum factors, including hopefully we will identify good environmental risk factors. And an environment, you know -- obviously there's always been a big contention about the role of the MMR vaccines. But environment can be things like, you know, if there's certain types of foods or certain types of vitamin supplements that change the environmental risk or that change the sort of the environment of the womb, that's one piece. You know, I mean, we know that certain medications -- you know, for example, women that have seizure disorders, if they're taking Valproate during seizures, almost half of those women have children with autism. So, we're now understanding that that's a risk factor for having a child with autism. And obviously, it's a terrible decision. If you have uncontrollable seizures and you have to take this medication, how do you balance that?

So, I mean, these are environmental risk factors that people are really actively pursuing and hopefully hold some promise. But all of this could be taken together, and we could understand what is this child's true risk factor? And by doing that, we can then understand that, we can then enroll them into sort of monitoring programs like in that first 36 months where we're looking at specific brain factors. Because if we know based on certain genes, we should see certain changes in the brain or certain changes in blood levels or certain changes in electrophysiological signatures, and so that we could sort of track whether this child's falling off this sort of typical developmental trajectory.

Finally, you know, and I think this is what I -- a lot of people are most excited about is prophylactic interventions. Right? Intervening before the symptoms occur. Heading it off before it happens. Almost like thinking about these as being a vaccination for autism. Like you're at risk so, you know, you get a vaccine that hopefully stops you getting, you know, the measles, mumps, or rubella. Hopefully we have an intervention for a child that's at high risk. We then can prevent or, you know, seriously reduce the impact of, you know, of the disorder developing by having this early intervention. So, I think this is where we'd like to see it. I have no timeline on any of this but, you know, this is where the investment is.

I think the culture of NIH has changed tremendously to say no more can you just do these studies to understand, what are the basic mechanisms? You have come back and tell us how you're making a difference. How are you treating it? How it's actually getting there. And I think you're going to see a lot of centers -- and CHOP, I feel, is in line of this -- of always trying to think about that initial model that I showed you of how do you go from the neurodevelopmental disorder to bringing it back around to that treatment? How are you connecting those dots together?

So, anyway. I'm going to stop there. I'll take questions. I think I'm close to the time. I spoke longer than I wanted to, but I wanted to give plenty of time for questions. So, yeah. Feel free. Sure. Go ahead.

Unidentified Female: Speak just a little bit more about the Tubular Sclerosis and that impact. Is there a correlation or causal effect? With autism and Tubular Sclerosis.

Dr. Yerys: Right. So, it's not causal. I mean, that's a great question. So, when we -- that's actually probably better if I do it this way. So, I mean, the argument here is not that Tubular Sclerosis or Fragile X is -- I mean, these are disorders that have a very specific genetic mutation and they're associated with autism. So, just like Fragile X, Tubular Sclerosis has about a 25-30 percent overlap of kids also having autism. And so, we look at this as whatever's affecting and causing Tubular Sclerosis, there's some other interaction that's also leading to autism. So, it's giving us some insight that the genes that affect Tubular Sclerosis are probably also involved in autism as well. But we understand what that gene is. And so, because we understand it's a single gene mutation, just like Down's Syndrome, where it's like you know what that is. And so, you're able to sort of target that and follow that much more closely. So, the argument here is just that -- not that's -- it's correlated, it's not causing, I guess is the way to think about it.

Unidentified Male: What kind of side effects are the kids with autism and ADHD experiencing from the Ritalin? And also, is there any correlation between how effective the Ritalin is and whether the kids have predominately inattentive or hyperactive ADHD?

Dr. Yerys: Yeah. That’s a great -- those are two great questions. In terms of the side effects, the most common one is irritability. And while Ritalin is a compound that we think of as affecting mostly dopamine, in the striatal system, the basal ganglia of the brain, we also know it affects norepinephrine. And norepinephrine influences serotonin. And so, when you disrupt the serotonin levels that's what we think is relating to the irritability as well. So, that's the most common.

Lesser side effects that come up, a small percentage of kids can develop an arrythmia, heart arrythmia. Like an atypical heartbeat. This is also true for kids with ADHD. So, for a while, you know, pediatricians, like, you know, a lot of doctors felt very comfortable using or sort of being prescribers. Now it's sort of shifted back to psychiatry and neurology because of these potential arrythmia issues.

The third one, and this is I think probably the hardest for clinicians to stomach -- and again, I'm a psychologist. I deal with behavior only. But I do feel the difficulty of it is, some kids actually develop tics as a result. And there's nothing worse as a provider with a family coming in with one problem and then having a second.

In terms of specificity to subtype, I have not heard anything specific to subtype. I think in terms of when you see the symptoms that are most impacted or affected, I would say that it's probably the hyperactivity that you see the bigger change in. I think that -- and mostly because that's what you see people rating the most. And, of course, for kids that are lower functioning, that maybe have -- their verbal skills aren't as good in sort of articulating what's going on, it's harder to tell if their attention is really improving or if they're just being quiet and being still.

But it's a great question. I think it's something that needs to be pursued further.

Unidentified Female: Is that for all the ADHD meds, or just Ritalin?

Dr. Yerys: Oh, that's a great question. So, I would say what's been used the most has been a variant of Ritalin, which a stimulant. There are non-stimulant based medications that have been used. The two most common that I'm seeing are Strattera and guanfacine. Guanfacine is also known as Intuniv. I don’t know how familiar some of you are with medications.

So, Strattera, you know, I generally -- what I've heard from most parents and talking with psychiatrists, they don’t feel like it's really super effective at all. But it doesn’t have the side effect issue. It doesn’t have the efficacies, and I haven't seen actually a really good trial yet on Strattera.

For guanfacine, Intuniv, I haven't seen a really good trial in autism, but I will tell you my clinical impression is that kids with -- psychiatrists and neurologists have been much more excited with using guanfacine, Intuniv. And it's actually -- its compound is actually a -- I'm trying to think of it, by the way -- it actually was originally a blood pressure medication. And so, it's actually hitting very different neurotransmitters than sort of the standard ADHD medications. And the fact that some people are finding it more effective may suggest, like as I said before, there may be a different physiology that's going on in the brain. This is actually something that we're actively pursuing. I have a grant right now to look at that in kids with autism. And so, that's something we're really excited to understand because we think that could relate to wanting to do something with Intuniv or guanfacine, to look at that.

Unidentified Female: I've seen better results with Adderall with less side effects than with Ritalin.

Dr. Yerys: Okay. I mean, I'm not a psychiatrist, so I can't speak to that. But, I mean, again, the drug trials that have been done have been used technically with methylphenidate, which is a variant of Ritalin. But yeah. I'm not sure if there's -- yeah, there could be lots of differences. If it's short versus long-acting. Yeah. Sorry. Another question.

Unidentified Female: You talked about the arrythmia and I was just curious with Vyvanse, if you've heard anything, any studies, on Vyvanse used for ADD or ADHD? With arrythmia.

Dr. Yerys: With arrythmia specifically? No. I don’t. I mean, and again, I'm not -- I mean, again, if you're talking about straight ADHD, the side effects that occur -- I mean, they are such a low percentage, you know, and I don’t know that -- I mean, again, it's really been more Ritalin, methylphenidate, that they've sort of polled that in on. Vyvanse specific, I don’t know. And again, as a child psychologist I sort of look at this to be -- try to be on top of the things that I can, but I'm not an expert. Yeah, on that side. Got a question in the back.

Unidentified Male: When you were talking about the long-term and short-term next studies, for the long-term, are there barriers to that? Is it technology barriers or just the length of time that it'll do it? Why are they considered long-term? When I'm looking at them they look like they could be more short-term.

Dr. Yerys: Right. That's a great question. I think the reason I think of them as being long-term is that some of that -- in order to really understand all the different genetic risk factors, I mean, right now we're talking about an international effort of like 10 or 11 countries trying to pool together 20,000-30,000 individuals with autism just to really understand all these different risk variants. I don't know how many years that's going to take for people to pull that together and how many lawyers are going to be involved to negotiate the data. I mean, I think that's a barrier is just sort of getting the sample sizes needed.

I think technology is definitely a barrier. We're getting better and better. I mean, a few years ago it was something like, you know, $16,000-$20,000 to do exome sequencing on the entire DNA of one person. That price has come down to like $10,000 because they found more efficient means. But, I mean, in order to make that really cost-efficient at the level that we're talking about, we're going to need a few more years where they'll hopefully get technology down where it'll be, you know, a few thousand. I think that's one of the -- probably the biggest barriers from the genetics side to pool that together.

The environmental risk factor side, I mean, I think the hardest thing about environmental risk factors is really finding a way to quantify the ones that are really going to play a role. And it's really, you know, it's a Herculean task and it feels overwhelming at times to identify them, but there are a lot of good leads out there and people are working on those. Looking at everything from, you know, water, location, air quality, you know, the type of prenatal care that people have. All these different factors. There are active studies. I can say some of them have been better funded and continuing more than others. But, I mean, again, we're hoping to sort of improve that. But I think those -- there's just the barriers, they're just getting that work down.

And you might be surprised to hear this, but there are a lot of parents who, when they have a child with autism, they don’t necessarily, if they have a second child, want to have them involved in research. And that's actually one of our best ways to understand some of these early risk factors, particularly if we're thinking about prenatal care or, you know, exposure to air quality and water quality. We have to follow kids when they're in utero, and unfortunately there are a lot of parents that they just don’t want to be under that kind of a microscope, and you can understand that. And it sort of goes both ways. Some parents are really gung-ho about it and some parents just don’t want that type of invasiveness.

So, there was a study that was sort of following that and tracking that for the last five years. They haven’t yet published their data. I'm really excited when -- if they find something, but I know that they are not prefunded in this next round that's coming up. So, you know, they sort of weren't as competitive as some of the other grants.

So, again, you know, and this is difficult. It's just the funding environment. You know, NIH is doing the best they can with their budget and, you know, they have to balance so many different disorders and diseases to study. And there's only so many grants. But it's a hard environment, but, you know, there's tremendous donors and, you know, we're working very hard to sort of pursue this research as a field, I would say. I mean, we know it's important. So, we'll keep trying. We'll try to make it short-range. I can't promise that.

So, I think it's -- our time is up now, right?

Unidentified Female: Yes. I think so.

Dr. Yerys: Thank you, guys.