330 – Autism, ADHD, and Anxiety: the rise in autism & an approach to diagnosing & treating children

KEYPOINTS

• 01

  Anxiety, ADHD and autism are clinical diagnoses based on impairment, not biomarkers.

  Sutcliffe, a developmental-behavioural paediatrician who founded a multidisciplinary Bay Area clinic, stresses there's no blood test or scan for any of them. Clinicians use DSM checklists, parent and teacher rating forms, history, clinic assessment and ideally school observation. The key question is whether traits impair a child's 'job'—learning, making friends, communicating, contributing at school. Anxiety itself is a normal emotion; it's about severity and pervasiveness.

• 02

  Each condition has its own diagnostic age window.

  Autism can be confidently diagnosed from about 18 months (rarely 15 months in obvious cases), though the typical age is 3–4 and half of cases are diagnosed after 6. ADHD can technically be diagnosed at 4, but Sutcliffe usually waits until 5–6 because preschoolers are a 'moving target,' while starting behavioural support earlier. Anxiety conditions—separation anxiety, selective mutism, phobias, OCD—appear in preschoolers.

• 03

  Self-esteem is the impairment Sutcliffe watches most closely.

  Children with ADHD get constant correction for forgetting, losing things and not finishing tasks, often from well-meaning adults. With elementary-age children, she asks about a 'third person'—why might another child come home crying?—because kids find it easier to describe others, and their stories reveal their own experience.

• 04

  Autism diagnosis requires differences in three social areas plus restricted or repetitive behaviours.

  The three areas are social reciprocity (back-and-forth, initiating and responding), nonverbal communication (eye contact, gestures, reading others' cues), and understanding relationships and group context. Since the 2013 DSM-5, Asperger's and PDD-NOS fall under one autism spectrum, specified with or without intellectual disability or language impairment. Severe cases can be diagnosed quickly; milder ones need multiple visits and outside perspectives.

• 05

  Autism prevalence has risen far beyond what criteria changes explain.

  CDC figures went from about 1 in 150–169 before 2013 to about 1 in 36 by 2020. Heritability is about 70–98%, higher than any other DSM condition, but it involves hundreds to roughly a thousand genes with a different 'fingerprint' in each child. Sutcliffe describes a multiple-hit gene–environment–epigenetic model, where timing and order matter. Implicated factors include pollution, maternal infection or prolonged fever, placental health, stress and parental age. Whether epigenetic marks pass across generations remains controversial.

• 06

  Level 1 autism is the blurriest category and often goes unsupported.

  Levels 1–3 range from 'requires support' to 'very substantial support.' Level 1 children have strong cognition and language but social and coping difficulties. One clinician may call it autism while another calls it ADHD plus anxiety. They often miss services despite responding very well to coaching on coping, change and social skills. Sutcliffe wonders whether the next DSM will swing back.

• 07

  The conditions overlap heavily.

  About half of autistic children also have ADHD (reports range 40–70%), a dual diagnosis only allowed since 2013, and about 40% have anxiety. ADHD 'frequently has a partner'—anxiety or mood issues, learning disabilities or oppositional behaviour. Imaging implicates frontal lobes, amygdala, cerebellum and temporal lobes.

• 08

  An 'ODD' label doesn't tell you what to do—find the function behind the behaviour.

  Arguing, lying and defiance may come from anxiety or embarrassment (very common), untreated impulsivity, social misunderstanding, or sensory overload. Each needs a different plan. Sutcliffe left the traditional model in 2014 because it amounted to 'you have autism, here's a list of 15 recommendations, good luck.'

• 09

  ADHD treatment: behavioural parent training first under 6, medication plus training from 6.

  Stimulants raise dopamine and norepinephrine in prefrontal synapses. Sutcliffe starts young children on methylphenidate (Ritalin, Focalin, Concerta), which meta-analyses show is slightly better tolerated. Amphetamines (Adderall, Vyvanse) give 'a bit more bang for your buck.' Formulations differ mainly in release mechanism, so switching brands can help. Common side effects are reduced lunchtime appetite and delayed sleep onset; some teens feel less funny or spontaneous, which calls for adjusting the dose or brand. Most families say 'I wish we'd started sooner.'