What Causes Autism Part 2: What Does The Science Show?

I'm Holly Wehment, and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner.

Click on the link in this podcast for free credit that may include CME, MOC, or ethics credit, depending on our topic or podcast. Joining me on the podcast today is Dr. Avinash Bodhapati. He's a child and adolescent psychiatrist. He specializes in neurodevelopmental disorders. Dr. Bodhapati, thank you so much for being here today on Pediatrics Now.

Thank you, Holly, for having me here. So we're talking about a hot topic today, and some pediatric practitioners are getting questions from their patients, from their families. The cause of autism. We have right now an episode out by Dr. Mario Fierro, our developmental pediatrician on faculty at UC Health, where he starts out the talk by saying, okay, stop here. If you want to stop here, go ahead, because what I'm going to say is we don't know what causes autism. Would you agree with that?

In some ways, I agree with that, because there is no one cause of autism. We know there are several risk factors or associated factors causing autism, but we don't have one single cause. And that's why you say there is some we understand about autism, what causes autism, but there is a lot more to be determined. Neurodevelopmental disorders is what inspired you to become a pediatric psychiatrist? That is correct. I always enjoyed working with the pediatric population,

but neurodevelopmental disorders definitely interest me. It's a very fascinating area. In simple terms, autism is a neurodevelopmental condition, which means it involves the brain and the nervous system. It's developmental, meaning the origin of the disorder is during the childbirth or early developmental period, meaning the first few years of life. It doesn't necessarily need to manifest birth.

So red flags, sometimes it can be as early as within a few months of birth and sometimes it is recognized only in later years of life when there is higher social demands or expectations.

Can you talk about some of those red flags?

At early birth not responding to the to the mother you know poor eye contact those are some of the things that you can notice during early periods and then later in life and later in life it again it depends upon the developmental age of the kid and it depends on what situation or environment they're in when they are going to school maybe or play in in the pre-tea preschool school years, it could be like not playing with other kids, having a typical interest or fixated interest.

Repetitive behaviors, not recognizing social communication, not understanding relationships, or having difficulty, not necessarily not understanding them completely, but having difficulty in interpreting them, understanding them.

And Avinash, when we talk about the causes of autism, what exactly do scientists mean? Are we talking about biology, genetics, environment, or a mix? That's a good question. So definitely a mix of everything. When I say everything, biology, the genetics, and then mind-blowing factors. So talking about the biology, we want to look at, okay, what are the changes in the brain or what is going on in the brain that manifests as these symptoms?

Why do people who have autism process things differently compared to a typically developing person. And there's definitely some known changes in the brain, whether it's the neurons, the pruning, there are some differences that we know of, but there's a lot more that we need to learn about.

And then when we talk about the genetic and the environmental factors, we want to know about, okay, what are those genetics and what are the environmental factors that impact this biology, what is causing the changes in biology or the brain? So we know there's a genetic role in autism, correct? If there's a child who has autism, his or her sibling has a higher chance of having autism? That is correct. Autism is a very highly hurtable disorder.

And some studies have shown that if someone has a sibling with autism, then their risk is they're 20 times more likely to have autism compared to the general population. So several studies have shown, twin studies have shown, that there is like 60 to 90% of autism risk is from the genes.

Are there specific genes or gene patterns that research consistently shows is linked to autism that we know of? Yes, this is definitely a big area of research. There are about 400 to 500 genes or even more genes or gene mutations that have been identified to be associated with autism.

But not all of them carry the same risk. there are some genes or there are certain genes which have a higher risk of causing autism or increasing the risk for autism most of the genes when we talk about the gene patterns most of them are associated the genes that code for proteins that are involved in synaptic meaning the neural which for synaptic connections. Proteins that code for like pruning, cell signaling pathways.

So a lot of those are the genes that are associated with increased, Like, will there be a day where there's genetic testing for the possibility of autism down the road? Yes, I think there would be a day. Right now, we test a lot of the kids or siblings who have autism to counsel the parents about the risk. Right now, one of the biggest issues in this area is that there's no one gene that we can say, okay, someone is positive for this gene or has this gene,

so they're definitely going to have autism. It just increases the risk, right? It's the gene and environment interaction that causes the outcome. So just because someone has the gene doesn't necessarily mean they're going to have autism. Now, their risk of autism increases. For example, Fragile X syndrome, which is the most common cause of intellectual disability or autism spectrum. Now, not everybody who has fragile legs definitely has autism spectrum.

They have a lot of features concerning for autism. Some of them do not have features consistent with autism, but at least 50 to 70 percent show ASD traits. Right. So their risk is increased, but that doesn't necessarily mean they'll definitely have autism. Okay. So, Avinash, that leads to my next question.

So beyond genetics, what environmental factors are being studied as possible contributors to autism? So in the past few decades, there have been like several environmental factors that have been studied. I would say... Maternal factors, maternal exposures. The main reason is because a lot of the hypothesis is that during the fetal development is when a change is occurring, which causes autism. And so there is a lot of emphasis on maternal factors.

One of the biggest factors is parental age. I know a lot of times we focus on maternal age, but it is also paternal age, which age 10-year increase in maternal age, there is about 50 to 20% increase in risk for ASD. Then maternal pregnancy conditions like maternal diabetes, obesity, uncontrolled hypertension, autoimmune disorders, they all increase the risk of a fetus having or an individual having autism. Any idea why that isn't talked about more? We've heard so much about Tylenol in the news.

Again, we need to understand we don't want to stigmatize just because someone has maternal diabetes or uncontrolled hypertension doesn't necessarily mean their kid is going to have autism. It just increases their risk. And the same way, I know the focus has been on Tylenol, but we know for certain there is a stronger association with other medications which can cause, when the fetus is exposed to certain medications in utero, there's a higher risk for developing autism.

A few examples would be like valproic acid or DAPCODE. It's a commonly used anti-epileptic medication. We also use it as a mood stabilizer. That has three to five times higher risk of ASD. Wow. So, but again, we always have to weigh the risks and benefits because untreated seizures have much more high risk for the fetus compared to valproic acid causing autism, right?

There are some medications, some of them are discontinued. Thalidomide is another medication, but it's no longer used, so it's not as much of a concern. Estamilofan and Tylenol, the concern is that it's a very frequently used medication, right? And when they looked at it, since I know it's a big debate, so I'll focus a little bit on that, when they look at it, yes, there is some possible association, but the association is not a very strong association, right?

And there are a lot of confounding factors. Even for the mild increase in risk. There's a lot of confounding factors and we don't know for sure. There has been no like good studies done. The counters, you know, it still needs to be, there is a lot more that needs to be done to say okay, does it really increase the risk or does it not? So it is possible, but is it now it's, there's just an association but that does not equal causation. That is correct. A very weak association.

I know probably a decade ago or two decades ago there has been concern about SSRIs, the commonly used antidepressants increasing the risk. And when they looked at the confounding factors, maternal depression itself is a risk factor for autism spectrum disorder. But when they looked at that confounding factor and they tried to take it away, then it showed that the antidepressants did not really increase the risk for autism.

So are there other environmental factors that used to be suspected, but that have now been largely ruled out that we don't have? For sure. I know one of the big ones is the vaccinations, particularly MMR vaccine. And it has been shown that there is no association and they do not increase their risk, whether it's in the maternal immunization or infant immunization, they do not increase the risk for autism spectrum disorder.

And is it true there's no evidence to show any vaccines increase child's risk of autism? Is that correct? That is correct. None of the vaccinations so far have been shown to increase the risk for autism spectrum disorder. On the other hand, maternal infections, they have some increased risk. And even childhood infections, not so much childhood infections, but maternal infections, particularly like the rubella, CMV, they have been strongly associated with autism. Hmm.

So not getting vaccinated can cause autism. That's scientifically proven. Not being vaccinated and having increased the risk for infection, which in turn, the infection itself can cause autism.

Well, this is all so interesting, Avinash. Are there any myths or misconceptions you'd like to clear up for pediatric clinicians? Hmm. For pediatric clinicians, per se, I know a lot of them are already, a lot of my pediatric colleagues are strong advocates. I know the vaccination is a big thing. The other thing is parents often come to us blaming themselves.

Now, learning about the diagnosis of autism spectrum disorder for a child having an autism spectrum disorder is hard for the parents by itself. And then they come in, what did I do wrong? And they kind of blame themselves. I think that's a big thing that we need to advocate for, saying that, okay, nobody, no parent, wantedly does anything, right? There are several things, and you cannot control all the risk factors.

So I think the pediatrician should kind of advocate and educate the parents that it's not them that's causing it. That's a great point, Avinash. I know you're a father of two, and I'm a mother of three, and there's so much guilt. It's so hard as a parent to not, whenever one of my kids is sick, I try to think of like, did I, what could I have done better? Or if they're in, even if they're in a horrible mood, I like somehow think it's my fault.

Exactly. I think we blame, you know, as parents blame themselves oftentimes and that's, that's, you know, there's only so much that you can control. And there are like several risk factors. It's not like, as I said, it's not like one risk factor. You cannot control the genes all the time. You cannot control what you're eating all the time. I mean, you can make healthy choices, but not necessarily control everything.

Is there any, I mean, of course, there's so many processed foods in our environment now. Are there any studies going on or happening about processed foods and any sort of link to autism? Or is that another myth? As of now, there is no strong association or no strong evidence to say that process causes autism. In fact, an interesting thing is that maternal smoking has been shown that it doesn't increase the risk for autism. Now, I know it's a controversial thing.

It does increase the risk for other medical conditions, but not really necessarily autism spectrum disorder. Similarly, so far, I'm not aware of any research that states or shows that processed foods are associated with a high risk for autism. They do increase other metabolic conditions and cause other medical conditions, but not necessarily autism spectrum disorder.

What are some promising areas of ongoing study? So genetics, the biggest area I would say is the gene environment infraction. That would be the biggest part. That would be the biggest emphasis for further research. And there is a lot of research going on there in that area. Because, okay, what predisposes, okay, a certain gene predisposes someone for autism. But what is that environmental factor and which genes and what environmental

factors are predisposing or increasing the autism risk? I think that's a good area where there is a lot of research going on. If we look at the autism as a whole, not just the causes, I think early identification of autism is an important thing which we need to emphasize on. And early recognition is important because early interventions, particularly in areas of social communication, helping them.

Training them, teaching them social skills or other accommodations, that has shown to cause difference in functioning. Now, autism is not something that, at least for now, autism is not something that we can cure, but we can improve the functioning of a person or an individual who has autism by changing the course. If we give them early social skills, early accommodations, early supports...

Only improves their functioning but it also lowers their risk of developing, psychiatric commodities like anxiety depression what what are the biggest gaps in research, on autism causes epigenetics meaning the gene drug interaction that is a big area again we have a We know there's a lot of environmental factors, and what is it?

I think that that's a big area. Avinash, why is it so difficult to pinpoint a single cause? Because there is no single cause, as we said, because there is multiple causes, so it is not something that's caused by one single thing. There is no one single cause for autism.

From the decades of research if there's one thing that we can take home today is that there's no one single thing that can cause autism for sure it's a it's a it's a it's multiple things and how would you say for pediatricians and pediatric practitioners in general listening how can understanding the causes of autism what we know and what we don't know how can this help them in their clinical practice so one of the things that we know for sure and i would like to re-emphasize vaccination

doesn't increase the risk for autism what excites you most about the future of autism research as far as the causes of autism it would be the epigenetics, that excites me as far as treatment the burial behavioral therapies.

Again, my focus is a little different because we look into the behavioral therapies, how to support individuals who have autism to make them as functional as possible without impacting their self-esteem or causing other psychiatric issues. And Avinash, you see patients in several locations. For our pediatric practitioner listeners in the San Antonio, South Texas area, can you quickly mention a few of those? You see patients at Clarity? I see patients at Clarity Child Guidance Center.

I also see patients at the NOW Adolescent Clinic, which is located within the main UT psychiatry building. Yeah. Saad, there's animals that, there's dogs who help with the therapy there too. Do you have anything to do with that? I'm not directly involved in that, but we do have a lot of therapy animals. We have a lot of volunteers bringing in therapy animals to assess patients. And the NOW Clinic parents can call to make an appointment. Is that correct?

It doesn't have to be a pediatric practitioner, the office staff calling. That is correct. Although you do not require a pediatrician to refer you, parents can just call the NOW Clinic. And that's for patients in Bexar County? That is open for patients in Bexar County. Yes. In addition to that, we also have... Go ahead. Sorry, I was... Are you going to lead into Morgan's Wonderland?

Yeah, I was going to say, I also see patients at the dual diagnosis clinic with the Center for Healthcare Services. It is located within the Morgan's Multi-Assistance Center, and it's right across Morgan's Wonderland and Thousand Oaks Drive. It's an incredible facility for all. Morgan's Multi-Assistance Center itself, the number would be the central number, which is 210-817-3935.

Great. So if you could leave Avinash Pediatric Providers with one takeaway about the science of autism causes, what would it be? There's no one cause for autism. It is multifactorial. And autism itself is like a huge autism spectrum disorder. We call it autism spectrum disorder for one reason. and it's a wide variety. If you have seen one kid with autism, you have seen only one kid with autism.

And so that makes it hard. So instead of focusing on one particular thing that causes autism, we need to identify the risk factors and try to prevent as much as possible. So if there's one point, there's no one cause of autism, don't let parents feel guilty or blame themselves for doing things a certain way. That's what I would encourage. Bottom line, we just don't know, but if it is Tylenol, there's a very small chance if that, or is that even going too far to say?

Based on the knowledge that we have or the information that we have so far, the risk, if at all there exists, there is a very, very, very weak association. Let me put it that way. Okay. It doesn't. So if someone needs Tylenol during pregnancy, discuss with the doctor, and I would say take it. Be the risks and benefits and take it. Thank you so much for your advice. And we have in our Pediatrics Now news feed an episode on vaccines. And our sister podcast is Pediatrics

Now for Parents. We will have a short episode with Dr. Bodapati. So we'll have an episode with you there where the pediatric practitioner can say, hey, here's this podcast for parents. And if you want to know more about the causes, what we know and what we don't know about autism, that's on Pediatrics Now for parents. Is there anything you want to mention before we wrap up? Avinash, this has been so insightful. I feel so honored to be able to talk to you here today.

No, I really appreciate the opportunity, Holly. I think this is a very important topic. Again, there is, as I've said it earlier, there is some that we know about autism. There is a lot more that we need to do. If you know anyone who has autism, I would like to say that they just process things differently. It's not, I do not consider it a disorder. A lot of kids who have autism spectrum disorder have a lot of strengths.

And again, each individual should be identified with the strengths that they have. That's such a great point to stress. Dr. Avinash Bodhapati with UT Health San Antonio, thank you so much for being here today on Pediatrics Now. Thank you.