GOOD AFTERNOON WE THOUGHT THAT THIS FINAL EXAM WE'VE BEEN TALKING ABOUT FOR THE PAST TWO WEEKS WAS GOING TO BE UP ELECTRONICALLY A FEW DAYS AGO BUT IT GOT DELAYED. THE REASON IT DELAYED WAS I HAD TO TAKE THE EXAM AND I MISSED ONE OF THE QUESTIONS. I WROTE IT. IT WAS A LITTLE BIT EMBARRASSING BUT I REALIZED IT WAS AMBIGUOUS SO WE CHANGED IT THE STARTING THE FIRST OF NEXT WEEK IT WILL BE UP ELECTRONICALLY AND IT WILL BE ATTACHED TO THE WEBSITE. ANYBODY, IT'S NOT A BIG DEAL. IT'S A LEARNING EXPERIENCE AND IF YOU DO THAT AND YOU COME TO HAVE THE SESSIONS OF THE COURSE AND WRITE IN AN EVALUATION YOU'LL RECEIVE A CERTIFICATE. AND NEXT WEEK, WE HAVE TWO VERY NOTABLE OUTSIDE PARTS PUPTS. THE TOPIC IS GLUTEN AND GLUTEN INTRINTERROPATHY AND CELIAC DISEASE AND SO FORTH. ANYBODY THAT GOES INTO A SUPERMARKET THESE DAYS CAN'T HELP BUT NOTICE THAT LEAST IN SOME SUPERMARKETS IT ALMOST LOOKS AS IF GLUTEN HAS TAKEN OVER. IT'S GOTTEN TO BE LIKE A RAGE. WE MAY HEAR A LITTLE BIT ABOUT IT EVEN TODAY. AT ANY RATE, NEXT WEEK -- ONE OF THE WORLD'S AUTHORITIES ON GLUTEN MECHANISMS WILL BE HERE AND ALSO IRV ROSENBERG WHO IS FROM TUFTS AND THE DIRECTOR OF THE HUMAN NUTRITION CENTER THERE. OKAY. SO IN THINKING VERY PREVIOUSLY, YOU KNOW, ABOUT AUTISM, MEDICINE IS FILLED WITH THESE SITUATIONS WHERE A DISEASE IS DESCRIBED SORT OF ANALOGOUS TO THE TIP OF AN ICEBERG AND THAT'S THE WAY PEOPLE ARE TAUGHT TO RECOGNIZE IT BUT THEN IT TURNS OUT WITH THE DEVELOPMENT OF DIAGNOSTIC TECHNOLOGIES, PROGNOSTIC TECHNOLOGIES, SUDDENLY THE WHOLE PHENOTYPE CHANGES AND IT'S NOT JUST THE TIP OF THE ICEBERG, IT'S LOTS. AND IT BECOMES THEN VERY DIFFICULT TO KNOW WHETHER IF THE TEST IS ABNORMAL. IT REALLY IS THE SAME DISEASE AND THAT'S A VERY COMMON THEME IN MEDICINE. YOU'VE HEARD IT THROUGH MANY OF THE PRESENTATIONS. NOW TODAY, IT'S MORE COMPLICATED BECAUSE THERE IS NO TEST UNLESS WE MAY HEAR OF ONE, BUT IT DOESN'T SEEM TO BE. AND SO WE'VE GOT THAT UNKNOWN OF THE EQUATION ON THE OTHER SIDE. SO FLFER IT' THEREFORE IT'S USEFUL TO GO BACK AND LOOK AT A LITTLE BIT OF HISTORY. SO YOU MIGHT ASK WHERE DID AUTISM EVER COME FROM AND IT WAS ORIGINALLY DESCRIBED BY A VIENNESE PHYSICIAN OR PSYCHIATRIST. I DON'T THINK THEY CALLED THEM THAT IN THOSE DAYS. THEY DID. SO HE USED THIS WORD AUTISM WHICH BASICALLY MEANS A LONER AND IT'S A PRETTY GOOD DESCRIPTION AND THAT'S A CLASSICAL DESCRIPTION WHICH WE'LL HEAR MORE ABOUT. SO THEN THE ICEBERG SPREADS AND YOU DON'T HAVE TO BE EXACTLY A LONER. AND YOU DON'T HAVE TO BE VIRTUALLY SPEECHLESS AND TOTALLY WITHDRAWN. THERE ARE WHOLE RAMIFICATIONS TO THIS SPECTRUM SO THE QUESTION IS, IS THIS ALL PART OF THE SAME DISEASE OR IS IT AN ICEBERG. AND NOW IF YOU READ THE NEWS AND LISTEN TO THE TELEVISION NEWS AND ALL THAT, SOMEHOW YOU GET THE FEELING THAT EVERYBODY, IF THEY AREN'T TALKING ABOUT AUTISM, THEY'RE TALKING ABOUT GLUTEN, IT'S BECOME SORT OF A TWO-TRACK MIND. I MEAN AUTISM IS ALL OVER THE PLACE. I STARTED COLLECTING SOME JUST NEWSPAPER ARTICLES OVER THE PAST MONTH OR TWO AND THEY'RE ON OUR WEBSITE. AND I WOULD ACTUALLY APPRECIATE IT IF THOSE OF YOU WHO HAVE BEEN COMING REGULARLY TO THE COURSE, GO TO THE WEBSITE AND LOOK AT IT BECAUSE I WOULD LIKE, WE MENTIONED NEXT WEEK YOUR CRITICAL OPINION OF THOSE ARTICLES. THEY'RE PUBLISHED, THEY LOOK VERY ELEGANT BUT LOOK AT THEM AS A SCIENTIST AND SEE WHAT YOU THINK. THAT'S PART OF ONE OF THE HUGE PROBLEMS WITH A DISEASE LIKE AUTISM. SO WE'RE IN A GENOMIC ERA AND THERE ARE FAMILIES AND MANOR ONE PATIENT IN A FAMILY. SO IS THIS GENETIC, HOW MUCH IS GENETIC. CAN YOU PREDICT ANYTHING. IS THERE REALLY SUSCEPTIBILITY. AND THEN ONE OF THE THING THAT FASCINATES ME IS IF YOU READ IN BIOGRAPHIES OF FAMOUS PEOPLE IN LITERATURE AND MUSIC AND SCIENCE LIKE SOME OF THE CHAPS, THERE ARE NO LADIES THERE. THERE ARE LADIES TOO BECAUSE THIS DISEASE DOESN'T HAVE A JERNLD BASIGENDER BASIS EXACTLY. BUT ALL THOSE PEOPLE, WERE THEY AUTISTIC THE WAY THEIR BIOGRAPHERS WRITE ABOUT THEM. SO MAYBE THESEAND OTHER QUESTIONS ARE THINGS THAT WE CAN PONDER WHILE OUR SPEAKERS TODAY WHO ARE EXPERT IN THIS AREA WILL LEAD US THROUGH THIS CONFUSING SITUATION. AND OF COURSE THE BOTTOM LINE IS, WHAT CAN YOU DO ABOUT IT. AND HOW DO YOU EVALUATE WHAT YOU'RE DOING WHEN YOU SORT OF MOVING AT TIMES AGAINST THE MOVING TARGET. SO THIS IS JUST SUPERFICIAL COMMENTS OF MINE AS A LIVER DOCTOR THINKING ABOUT AUTISM BUT NOW WE'RE GOING TO HAVE TWO EXPERTS DISCUSS THE REAL ISSUES. SO OUR FIRST SPEAKER TODAY IS AUDREY THE THERM WHO HAS A PH.D. THIS PSYCHOLOGY AND WORKS HERE AS A STAFF SCIENTIST AT THE NIH. AND IT'S BEEN PARTICULARLY INTERESTED IN THE EARLY DETECTION OF AUTISM AND PARTICULARLY IN YOUNG CHILDREN WHICH WE WILL HEAR ABOUT. AND THEN OUR SECOND SPEAKER IS SUSAN SWEDO WHO IS THE HEAD OF THE BRANCH OF CHIEF OF THE PEDIATRICS AND DEVELOPMENTAL NEUROSCIENCE BRANCH. SHE HAS BEEN AT NIH SINCE 1986 AND GRADUATED IN MEDICAL SCHOOL FROM SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE AND THEN WAS TRAINED AT NORTH WESTERN AND CAME HERE TO THE NIH AND HAS DONE SOME REALLY ASTOUNDING WORK IN STUDIES OF AUTISM. I DIDN'T KNOW ANYTHING ABOUT PANDA, WHICH STANDS FOR PEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISEASE. WHICH SUSAN IDENTIFIED AS BEING RELATED TO AN AUTO ANTIGEN IN HEMO LYTIC TRI STEP TOE CAUCUS. I HOPE WE'LL HEAR ABOUT THAT TOO EVEN THOUGH IT'S NOT ON THE TOPIC. THANK YOU TO BOTH OF YOU VERY MUCH. SO WOULD YOU LIKE TO BEGIN. >> GOOD AFTERNOON, EVERYONE. CAN YOU HEAR IN GREAT. I AM VERY THANKFUL FOR THAT INTRODUCTION BECAUSE WE WANT TO DO EXACTLY THAT TODAY IS KIND OF TAKE A STEP BACK AND I'M REALLY GOING TO TALK ABOUT AUTISM AS I WAS TAUGHT ABOUT IT WHICH WAS NOT THAT LONG AGO BUT LONG ENOUGH THAT THINGS ARE A LITTLE DIFFERENT. WE'LL START OUT BY SAYING WE HAVE NO DISCLOSURES. SO IN THIS FIRST PART OF THE PRESENTATION, I'M REALLY GOING TO TALK ABOUT THE PRESENTATION OF -- THE DEFINITION, THE CURRENT CRITERIA AS IT STANDS RIGHT NOW, HOW IT LOOKS, CLINICAL MANIFESTATIONS, HOW WE DIAGNOSE IT. WE DON'T HAVE A PERFECT TEST BY ANY MEANS AT THIS POINT. AND I'M REALLY GOING TO EMPHASIZE AND START, IF I REPEAT MYSELF, I'M GOING TO EMPHASIZE A LOT DEVELOPMENTAL CHANGES BECAUSE THIS IS A DEVELOPMENTAL DISORDER AND IT DOES CHANGE. OVER DEVELOPMENT. SO I'M FIRST GOING TO TALK ABOUT THE WAY WE DIAGNOSE IT RIGHT NOW. AS A PSYCHIATRIC DISORDER IT'S LISTED AS A PSYCHIATRIC DISORDER ALTHOUGH IT IS A NEURODEVELOPMENTAL DISORDER, IT IS LISTED IN THE DIAGNOSTIC MANUAL FOR MENTAL DISORDERS. THAT'S THE BOOK THAT HAS ALL THE DEFINITIONS OF PSYCHIATRIC DISORDERS. AND THERE ARE SPECIFIC CRITERIA FOR AUTISTIC DISORDER. I'M GOING TO START WITH THAT AND I'M GOING TO GET INTO THE FULLER PICTURE OF ASD. SO I JUST SEE HERE, IT IS WHAT WE CALL THE CHINESE MANUAL APPROACH THAT YOU NEED TO HAVE FOR AUTISTIC DISORDER, YOU NEED TO HAVE CERTAIN CRITERIA OUT OVER OF ALL THE DIFFERENT POSSIBILITIES. SO THIS IS THE FIRST A CRITERIA WHICH IS A QUALITATIVE IMPAIRMENT IN SOCIAL INTERACTIONS AND MAYBE MANIFEST BY AT LEAST TWO OUT OF THESE FOUR CRITERIA. I'M TOGETHER TO GO THROUGH EACH ONE AND TRY TO GET SOME EXAMPLES. SO THE FIRST ONE IS MULTIPLE IMPAIRMENT AND MULTIPLE NON-VERBAL BEHAVIORS. WE'LL HEAR THEY ARE DESCRIBED AS EYE CONTACT. IT DOESN'T MATTER WHAT I'M SAYING RIGHT NOW, IT MATTERS WHAT I'M DOING. USING EYE CONTACT, GESTURES, BODY POSTURES, FACIAL EXPRESSIONS. MAYBE MINE IS A LITTLE BIT ON THE EXTRA SIDE RIGHT NOW BUT WE'LL TRY TO CHANGE THAT. AND ALL THESE THINGS WE DO IN LIFE. SO HAVING AUTISM DOESN'T MEAN THAT YOU DON'T DO ANY OF THESE THINGS. IT MEANS THERE'S A MARKED IMPAIRMENT IN THAT. MARKED IMPAIRMENT MEANS IT IS AFFECTING HOW YOU GET AROUND IN THE WORLD. THAT'S HOW MARKED IMPAIRMENT MEANS. IT'S MARKED, IT'S NOTICEABLE AND IT'S IMPAIRING. IT MAKES LIFE WORSE FOR YOU. I THINK THAT'S PART OF THE PIECE WE NEED TO ALSO CONTINUE TO TALK ABOUT. THAT'S A KEY AND PROBABLY WHY IT'S A-1 IS THAT, THOSE NON-VERBAL COMMUNICATION BEHAVIORS WHICH ACTUALLY GO INTO THE SOCIAL DOMAIN AND WE'LL GET BACK TO THAT TOO. THEN THAT SOCIAL DID HE MAIN WHICH MAKES SENSE -- DOMAIN WHICH MAKES SENSE, PEER RELATIONSHIPS, THAT'S SOCIAL. HAVING A FAILURE TO DEVELOP PEER RELATIONSHIPS APPROPRIATE AT DEVELOPMENTAL LEVELS AND WE'RE GOING TO TALK A LOT ABOUT THAT PART. SO YOU KNOW, NOW WE'RE TOLD THAT WE NEED TO DIAGNOSE TWO YEAR OLDS OR ONE AND-A-HALF YEAR OLDS. I DON'T THINK THIS IS QUESTION AND ANSWER BUT I COULD EVERYONE WHAT A TYPICAL PEER RELATIONSHIP LOOKS LIKE IN AN 18 TO 20 MONTH OLD. I CAN TELL YOU IT JUST MEANS THEY'RE LOOKING AT OTHER KIDS IMITATING THEM, MAYBE GRABBING SOMETHING FROM THEM. IMITATING IS KEY HERE AND JUST SHOWING INTEREST. BUT CLEARLY AS WE GET OLDER, OUR RELATIONSHIPS ARE SUPPOSED TO GET A LITTLE MORE INTRICATE AND WE CAN TALK ABOUT HOW THAT GETS AFFECTED. BUT THE DEVELOPMENTAL LEVEL IS KEY HERE AND I'LL KEEP ON COMING BACK TO THAT. AND THEN THE IMPAIRMENT IN SEEKING TO SHARE PLEASURE WITH OTHERS. AGAIN, I'M GOING TO FOCUS ON THE TWO YEAR OLDS BECAUSE THAT'S WHAT WE'RE SUPPOSED TO BE AND WE ARE GOING TO SEE EXACTLY ABOUT THAT. WHEN YOU'RE SHARING YOUR PLEASURE WITH SOMEONE ELSE, WHEN YOU'RE TWO YOU'RE REALLY JUST TRYING TO GET THEM INVOLVED. WHEN YOU'RE OLDER YOU'RE TRYING TO TELL THEM ABOUT YOUR DAY, MAYBE ABOUT WHAT YOU DID AT SCHOOL OR WORK OR THINGS LIKE THAT. AND THEN HARDEST TO DESCRIBE IS SO SO EMOTIONAL RECIPROCITY. WHAT IS THAT. I WILL THANK DR. GREENSPAN FOR GIVING THE BEST DESCRIPTION OF THAT AND THAT IS ESPECIALLY FOR A TODDLER THE DANCE BETWEEN PEOPLE. SO IT DOESN'T REALLY MATTER WHAT YOU'RE DOING, IT'S HAVING THAT BACK AND FORTH THAT HAS AFFECT TO IT AND THAT SHOWS YOU WANT TO KEEP IT GOING. SO I GIVE THE DESCRIPTION HERE IS I ACTUALLY HAVE CHILDREN WITH MAUTISM IS BEING PEACEABLE WITH THEIR PARENTS BUT IT'S HOW THEY ARE DOING IT AND WANTING TO CONTINUE. IT'S A QUALITATIVE THING AND IT'S VERY HARD TO DESCRIBE BUT IT'S THAT KIND OF RECIPROCITY THAT IS THE IMPAIRMENT. AND OBVIOUSLY LATER ON IN LIFE AND IF YOU'RE VERBAL AND YOU'RE HIGHLY INTELLIGENT IS IT MIGHT BE HAVING A VERY HIGH LEVEL CONVERSATION ABOUT COMPUTERS BUT NEVER ENGAGING ASKING THE OTHER PERSON WHAT THEY KNOW ABOUT IT GETTING BACK AND FORTH. SO THAT'S THE SOCIAL DOMAIN. THE NEXT DOMAIN IS QUANTITATIVE IMPARENTS IIMPARENTS INIMPARENTSIMPAIRMENT S. TWO NEEDS TO BE IN THE SOCIAL DOMAIN THAT'S A CLUE THAT'S TO BE MORE IMPORTANT. ONLY ONE NEEDS TO BE IN THE COMMUNICATION. HERE IT'S A DELAY OR LACK OF DEVELOPMENT OF POKEN LANGUAGE THAT'S ONLY HALF AND THE OTHER HALF IS ABLE TO COMPENSATION. BACK TO NO, SI THOSE NON-VERBAL COMMUNICATION CRITERIA I DESCRIBED BEFORE. IMPEOPLE WITH HEARING IMPAIRMENTS MIGHT HAVE A HARD TIME LEARNING LANGUAGE. THERE'S MANY REASONS WHY PEOPLE HAVE A HARD TIME LEARNING LANGUAGE. IT'S NOT THE LANGUAGE DELAY IT'S THE COMPILATION WITH IT AND THAT'S REALLY REALLY KEY BECAUSE ESPECIALLY WHEN WE'RE TALKING ABOUT DIAGNOSING VERY YOUNG CHILDREN, MANY MANY CHILDREN HAVE LANGUAGE WAYS WITH HUGE VARIABLE TEASE WITH LANGUAGE DEVELOPMENT -- VARIABILITIES WITH LANGUAGE DEVELOPMENT ITSELF. IT'S NOT HAVING LANGUAGE DELAY IT'S WHAT YOU'RE NOT DOING TRYING TO COMMUNICATE AND BE SOCIAL IN THE ABSENCE OF THAT. THEN IF YOU DO DEVELOP LANGUAGE, IT'S THAT CONVERSATION, THAT BACK AND FORTH. AND YOU CAN START TO SEE NOW WHY I ALREADY TALKED ABOUT CONVERSATION AS SOCIAL WHY THESE THINGS ARE ACTUALLY HUGE FEELINGS AND WE'LL TALK ABOUT WHEN WHAWHAT THAT'S GOING TO MEAN FOR FUTURE CRITERIA. WITH LANGUAGE THERE IS IMPAIRMENTS OR QUALITATIVE DIFFERENCE IN THAT KIND OF LANGUAGE THAT IS USED SUCH THAT SOMEONE MIGHT BE TALKING REPETITIVELY ABOUT THE SAME TOPIC OR REPEATING THINGS THAT ARE OUT OF CONTEXT. IT'S NOT THE SAME LINES FROM YOUR FAVORITE MOVIE A COUPLE TIMES, IT'S REALLY REPEATING THEM AND NOT USING THEM APPROPRIATELY IN THE CONVERSATION IN THE BACK AND THE FORTH. AND THEN THE ONE THAT I LIKE THE BEST IS ABOUT PLAY BECAUSE THAT IS WHAT CHILDREN DO AND THAT IS HOW THEY COMMUNICATE. BUT IT'S AN IMPAIRMENT AND MAKE BELIEVE PLAY WHICH AGAIN IS HOW CHILDREN LEARN A LOT OF WHAT THEY LEARN. ESPECIALLY ABOUT HOW TO BE IN THE WORLD AND HOW TO INTERACT WITH OTHER PEOPLE APPROPRIATE TO DEVELOPMENTAL LEVELS. AND THAT CAN BE SOCIAL IMITATIVE. WE ALREADY TALKED ABOUT PEEK-A-BOO AND THINGS LIKE THAT BUT MUCH MORE ELABORATE. YOU'RE GOING TO BE THE BAD GUY I'M GOING TO BE THE GOOD GUY THAT KIND OF BACK AND FORTH PLAY THAT'S A LOT OF WHAT CHILDREN DO. SO THAT GOES UNDER COMMUNICATION BECAUSE THAT'S AGAIN WHAT KIDS DO. SO THE FIRST TWO CRITERIA I TALK ABOUT AGAIN ARE SOCIAL COMAITIONDZ THAT ARCOMMUNICATIONS THAT ARE VERY LINKED TO EACH OTHER. THIS IS PART OF WHY AUTISM IS MORE DIFFICULT THAN A LOT OF OTHER PSYCHIATRIC AND OTHER ILLNESSES IS BECAUSE IT'S DEFICITS IN THESE THINGS. IT'S THE LACK OF DEVELOPMENT OR THE LACK OF SHOWING OF THOSE SKILLS. SIMILAR TO MAYBE THE NEGATIVE SYMPTOMS THE SCHIZOPHRENIA WHERE YOU'RE NOT DOING WHAT YOU SHOULD BE. HERE'S THE THIRD CRITERIA IS DOING SOMETHING THAT YOU SHOULDN'T BE DOING AND THAT IS EITHER HAVING A RESTRICTED OR REPETITIVE PATTERN OF INTEREST OF BEHAVIORS. SO THE ONE THAT'S SORT OF MOST CLASSIC AND IS EASY TO SEE BUT NOT NECESSARILY EASY TO DISTINGUISH AUTISM IS REPETITIVE MOTOR MANNERISMS, FLAPPING YOUR HANDS, JUMPING UP AND DOWN REPEATEDLY, SPINNING PAND AND DOING SPECIFIC MOVEMENTS WITH YOUR HANDS. THESE ARE THINGS THAT WE DO SEE IN TYPICAL DEVELOPMENT. WE ALSO SEE IN OTHER INTELLECTUAL DISABILITIES BUT THEY ALSO DO GO ALONG WITH AUTISM. THEN THE REST, THE NEXT ONE IS SORT OF HOW YOU PLAY WITH THINGS OR HOW YOU INTERACT WITH OBJECTS. SO THIS IS HAVING YOUR PREOCCUPATION WITH A PART OF AN OBJECT. SO INSTEAD OF OPENING A BOTTLE OF BUBBLES A CHILD MIGHT SPEND THEIR TIME ROLLING IT BACK AND FORTH, SPINNING THINGS, LOOKING AT HOW SHINY SOMETHING IS, A SENSORY COMPONENT TO IT RATHER THAN USING AN OBJECT AS IS INTENDED. THE NEXT ONE IS ENCOMPASSING PREOCCUPATION WITH THE RESTRICTIVE PATTERN OF INTEREST. SO THIS IS ALREADY IN MY MIND I STARTED TO THINK ABOUT OLDER PEOPLE HERE OR PEOPLE THAT ARE MORE VERBAL WHO CAN START TALKING ABOUT ME OCCUPATION, SOMETHING THAT THEY'RE INTERESTED IN. WHAT THAT PRE OCCUPATION MIGHT CHANGE OVER DEVELOPMENT BUT IT'S SOMETHING THAT MIGHT EITHER BE A NORMAL INTEREST, LIKE LET'S SAY TRAINS FOR FOUR YEAR OLD BOYS. THAT IS VERY VERY EXCESSIVE. AND NOT SOCIAL IN NATURE OR IT COULD BE SOMETHING, YOU KNOW, SOMETHING THAT THE PERSON REALLY GETS CARRIED AWAY WITH AND MAYBE KNOWS A LOT ABOUT BUT DOESN'T USE THAT IN A HELPFUL WAY. THE LAST ONE IS AN APPARENT COMPULSIVE ADHERENCE TO A SPECIFIC NON-FUNCTIONAL ROUTINE OR RITUAL. YOU START TO THINK ABOUT OCD HERE BUT FIRST IT'S NOTED AS NON-FUNCTION ROUTINES. THIS KIND OF THING MIGHT BE WALKING INTO A ROOM, TOUCHING A TABLE AND SPECIFIC AROUND AND -- SPINNING AROUND AND TURNING A LIGHT ON AND HAVING TO DO IT IN THAT ORDER BUT NUT NECESSARILY LEARN IT THAT WAY BUT STARTING TO DO IT THAT WAY. THIS CAN BE ROUTINE, ALTHOUGH THINGS YOU WOULD NORMALLY DO AND JUST VERY VERY VERY COMPULSIVE ABOUT IT. SO AGAIN, YOU NEED TO HAVE SIX OF THOSE TO MEET FOR AUTISM AT THIS POINT IN TIME WHILE THE DSM4, THAT'S THE VERSE THAT IS CURRENTLY IN USE. YOU ALSO NEED TO HAVE AN ABNORMAL IMPAIRED DEVELOPMENT. YOU NEED TO SHOW SOME OF THESE THINGS, SPECIFICALLY SOCIAL INTERACTION DEFICITS, LANGUAGE DEFICITS USED IN SOCIAL COMMUNICATION AND THAT PRO DEFICITS, YOU NEED TO HAVE THESE BY THE AGE OF THREE IN ORDER TO HAVE FULL CRITERIA FOR AUTISM. AND THAT IS NOT BETTER ACCOUNTED FOR BY SOME OF THE OTHER ASD'S. SO WHAT ARE THE ASD'S. THIS IS THE WAY IT LOOKS RIGHT NOW AND I'LL BE BRIEF BECAUSE THIS IS GOING TO BE CHANGING. BUT RIGHT NOW, WHAT WE WOULD CALL THE WHOLE AUTISM SPECTRUM INCLUDES AUTISM AS THE MOST SORT OF SEVERE OR THE PROTOTYPE, AND AGAIN WE ALREADY HEARD EXACTLY WHAT YOU NEED TO MEET CRITERIA FOR THAT. THE BIGGER CIRCLE WHICH IS INDICATING LESS SEVERITY IS WHAT WE CALL PDDNOS RIGHT NOW PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED. FOR THAT RIGHT NOW BELIEVE IT OR NOT, OUR BOOK WAS SUPPOSED TO DEFINE IT, ACTUALLY DOESN'T HAVE ANY SPECIFIC NUMBER OF CRITERIA THAT YOU CAN HAVE FOR THIS. SO JUST KEEP THIS IN MIND AS WE MOVE AUTHORIZE THE SECOND PART OF OUR TALK WHERE WE'RE GOING TO TALK ABOUT PREVALENCE RATES AND THINGS THAT ARE CHANGING. AGAIN KNOWING THAT THE BOOK THAT HELPS US DEFINE IT DOESN'T GIVE US A NUMBER OF THESE CRITERIA THAT YOU NEED TO HAVE. IT DOES NEED TO SAY, IT SAYS THAT YOU NEED TO HAVE SOME SOCIAL CRITERIA THAT ARE IMPAIRING BUT IT DOESN'T, IT SAYS IT DOESN'T HAVE TO BE AT THE LEVEL OF AUTISM OR IT DOESN'T GIVE YOU AN AMOUNT. I WILL TALK VERY BRIEFLY ABOUT THESE OTHER DISORDERS, ASPERGER'S DISORDER IS RELATED IN TERMS OF HAVING SOCIAL DEFICITS AND THE REPETITIVE BEHAVIOR DEFICITS THAT WE ALREADY OUTLINED. IT SPECIFICALLY SAYS THAT YOU CANNOT HAVE A COGNITIVE IMPAIRMENT TO HAVE ASPERGER'S DISORDER AND YOU CANNOT HAVE LANGUAGE DELAY. THAT'S REALLY THE DIFFERENCES IN THE CRITERIA RIGHT NOW AND WE'LL TALK A LITTLE BIT MORE ABOUT HOW THOSE DIFFERENCES HAVEN'T REALLY PANNED OUT IN TERMS OF RESEARCH LOOKING FOR BIOLOGICAL DIFFERENCES BETWEEN THESE DISORDERS WHICH IS WHY MAYBE USING SEPARATELY BOTH MIGHT NOT BE HELPFUL IN THE FUTURE. CHILD 407D HOCHILDHOOD DISINTEGRATIVE DISORDER IS A SPECIFIC FIVE IN WHICH THERE IS NORMAL DEVELOPMENT AT LEAST UNTIL THE AGE OF TWO AND THERE'S A VERY SEVERE AND MARKED REGRESSION. THIS REGRESSION DOESN'T NECESSARILY LEAD TO THE EXACT SYMPTOMS OF AUTISM. SO IT'S FELT THAT THIS DISORDER HASN'T BEEN STUDIED ENOUGH MAYBE TO REALLY THINK OF IT AS SEPARATE ALTHOUGH THERE CERTAINLY ARE CHILDREN WHO HAVE AUTISM AND ALSO CHILDREN WHO DON'T HAVE AUTISM WHO HAVE MARKED REGRESSIONS IN TERMS OVER HAVING DEVELOPMENT AND THEN LOSING SKILLS. REST DISORDER. WHEN THIS PARTICULAR VERSION OF THE DSM CAME OUT, IT WAS PRIOR TO HAVING A GENE IDENTIFIED FOR REST DISORDER WHICH IS A VERY SPECIFIC AND ALSO RARE DISORDER THAT WE THINK AFFECTS MOSTLY THREE YEARS OLD, HAS A GENE IDENTIFIED TO IT AND DOESN'T NECESSARILY LOOK LIKE AUTISM EITHER WHEN CHILDREN GET OLDER. THERE'S A DECELERATION OF HEAD GROWTH. THERE'S ALSO REGRESSION, THERE'S A VERY SPECIFIC HAND RINGING AND THERE'S OTHER MEDICAL ASPECTS TO IT. SO AGAIN, AS WE MOVE TOWARDS DSM5, WE'RE GOING TO BE THINKING MORE ABOUT CRITERIA FOR AN ASD, ONE ASD AND I'LL GET TO THAT IN A MINUTE. SO AT THIS POINT, OOPS. AT THIS POINT I JUST WANT TO SHOW THIS VERY BRIEFLY TO SHOW AND REMIND OURSELVES THAT COGNITIVE AND LANGUAGE IMPAIRMENTS ARE THINGS THAT VERY OFTEN GO ALONG WITH AUTISM OR ASD'S. I'VE ALREADY ALLUDED TO IT IN TERMS OF THE FACT THAT IT'S EITHER SOMEWHERE BETWEEN 40-70% DEPENDING ON THE STUDY OF INDIVIDUALS WITH AUTISM ALSO HAVE COGNITIVE IMPAIRMENT. SO JUST IN TERMS OF THINKING ABOUT HOW WE THINK ABOUT THESE CRITERIA, THAT THEY NEED TO BE CONSIDERED IN TERMS OF COGNITIVE LEVELS. SO IF YOU ARE SEVEN BUT ONLY HAVE THE COGNITIVE LEVEL OF THE THREE YEAR OLD, WE NEED TO BE THINKING ABOUT SOCIAL IMPAIRMENTS MORE RELATED TO A THREE YEAR OLD THAN TO A SEVEN YEAR OLD IN MAKING THE DIAGNOSIS. SO NOW I'LL JUST SHOW BRIEFLY AS I ALREADY MENTIONED THAT HERE THIS IS REALLY ALL RIGHT NOW WORKING WITH MULTIPLE CIRCLES AND THIS IS WHAT WE'LL BE MOVING TOWARDS IN THE DSM5, WE THINK. THIS IS SPECULATION RIGHT NOW. IT IS NOT FINALIZED, BUT IT IS THE PREVIEW IS INDICATING THAT WE'RE LOOKING TOWARDS COMBINING SOCIAL COMMUNICATION, HAVING REPETITIVE BEHAVIORS DEFINED A LITTLE BIT DIFFERENTLY AND HAVING ONE DIAGNOSIS FOR ASD WHICH WILL BE TALKED ABOUT A LITTLE BIT FURTHER. SO I'M GOING TO GET, WE'VE ALREADY TALKED A LITTLE BIT ABOUT HOW HEADLINES MIGHT MAKE THINGS CONFUSING. A MYTH IS THAT AUTISM IS JUST ONE DISORDER. I THINK AS YOU'VE BEEN HEARING ME TALK ABOUT THE CRITERIA, WE REALIZE THAT THERE MAY BE A HUGE VARIETIES OF SEVERITY AND TYPE OF SYMPTOMS THAT CAN BE DISPLAYED. SO THE REALITY IS THAT IT'S QUITE HEATHRO HERETO HEATHROW GENIUS HEAT HETEROGENEOUS. MOST PEOPLE TALKING ABOUT TECHNOLOGY ARE NOT TALKING ABOUT THE SEVERITY BUT MORE ABOUT LANGUAGE LEVEL AND IQ WHEN THEY'RE MAKING THESE GROUPINGS SO WE NEED TO KEEP THAT IN MIND. PARTLY BECAUSE WE HAVEN'T HAD A GOOD METHOD OR TEST FOR MEASURING SEVERITY. BUT WE DO KNOW THAT SEVERITY CAN VERY RELATIVELY INDEPENDENTLY ON EACH OF THE DOMAINS ALREADY TALKED ABOUT, AND WE ALSO KNOW THAT EXPRESSION OF SYMPTOMS CAN CHANGE OVER TIME OVER A LONG PERIOD OF TIME THROUGHOUT THE LIFETIME BUT ALSO THROUGHOUT A SHORT PERIOD OF TIME. SO STARTING TO THINK ABOUT WHY WE HAVE SO MUCH TROUBLE DIAGNOSING THIS AND KEEPING TRACK AND SEEING IF WE CAN MEASURE SUCCESSFULLY TREATMENTS, YOU'RE GETTING THE IDEA HERE. SO AGAIN, I SAID I WOULD BE REPETITIVE ABOUT THIS AND I WILL BE, THAT THE WAY THE SYMPTOMS GET PRESENTED ARE GREATLY INFLUENCED BY THE MENTAL AGE OF THE INDIVIDUAL AND THE LANGUAGE LEVELS. AND THEN IT'S PROBABLY NOT DARK ENOUGH HERE BUT CLEARLY YOUR BIOPSYCHOSOCIAL CONTEXT, WHERE YOU LIVE, WHAT'S AROUND YOU, WHAT KIND OF TOYS YOU'RE GIVEN, YOUR SCHOOLING, YOUR ENVIRONMENT, WHETHER YOU HAVE SIBLINGS AND CERTAINLY BIOLOGICAL DIFFERENCES WILL EFFECT HOW THESE SYMPTOMS GET EXPRESSED. THIS IS A VERY VERY BUSY SIDE WHICH JUST SHOWS HOW EVEN WITHIN THE CRITERION HERE I'VE OUTLINED THEM MORE LOOKING IN THE DSM5. WE REALLY CAN'T LOOK, WE CAN SAY THAT OVER THE WHOLE COURSE OF THE LIFE, AND THIS IS NON-VERBAL OR VERBAL JUST BREAKING IT UP WE ARE KNOW THERE CAN BE SOCIAL AND EMOTIONAL RECIPROCITY BUT AGAIN HOW THAT MIGHT LOOK, HOW YOU'RE GOING TO TRY TO DIAGNOSE IT IS GOING TO BE DIFFERENT. IT'S GOING TO BE BOO PAYING PEAK-A-INTO WITH TOYS AND HOW YOU DO SPAN INTERVIEW FOR A JOB WHEN YOU'RE AN ADULT AND YOU'RE VERBAL. IT'S JUST POINTING OUT SOME INTOOFT DISHESOFTHE DIFFERENCES HERE. POINTING OUT THE CHILD RELATIONSHIP HERE AND MOVING TOWARDS RELATIONSHIP WITH CHILDREN AND FRIENDSHIPS AND LOOKING HOW THEY ARE AFFECTED WHEN CHILDREN GET OLDER. THE TYPES OF STEREOTYPES AND REPETITIVE SYMPTOMS WILL CHANGE DEPENDING WHETHER YOU'RE VERBAL OR WHAT PART OF LIFE YOU'RE IN. SO JUST AGAIN, SUMMARIZING THAT WE NEED TO THINK ABOUT AUTISM AS A DEVELOPMENTAL DISORDER THAT AUTISM AFFECTS YOUR DEVELOPMENT. SO THE FACT THAT YOU'RE HAVING DEFICITS, IMPAIRMENTS IN SOCIAL AND EMOTIONAL RECIPROCITY, YOU'RE NOT SEEKING IT OUT, YOU'RE NOT DOING WHAT 12 MONTH OLDS AND 18 MONTH OLDS DO ALL DAY LONG WHICH IS PUT ITEMS IN FRONT OF PEOPLE AND HAVE THEM BE NAMES SO YOU CAN LEARN THEM. AND WHEN YOU WANT THEM, ALL THESE KIND OF THINGS. WHEN YOU'RE NOT DOING THOSE THINGS, YOUR WORLD IS GOING TO BE DIFFERENT EVEN IF YOU HAVE PARENT WHO ARE TRYING TO BE ATTENTIVE AND YOU GOT THERAPISTS WITH YOU ALL THE TIME. YOU'RE NOT GOING TO GET THE SAME INPUT FROM OTHER PEOPLE AND THAT WILL AFFECT YOUR DEVELOPMENT. AUTISM IS CERTAINLY AFFECTED BY DEVELOPMENT. WE DON'T KNOW BIOLOGICALLY HOW THAT HAPPENS BUT WE DO KNOW INTERESTS THAT PEOPLE HAVE CHANGE OVER TIME AND THAT THEY CHANGE OVER TIME AND PEOPLE WITH AUTISM SO THAT IT MIGHT MOVE TO OTHER TOPIC AS YOU GET OLDER. SO NOW HOW DO WE DIAGNOSE AUTISM. SO WE ARE TRYING AND CERTAINLY THERE ARE MAJOR MAJOR EFFORTS OUT THERE TO DIAGNOSE IT AS YOUNG AS POSSIBLE, ALTHOUGH THE RESEARCH IS STILL VERY LIMITED ON TREATMENTS. WE DO KNOW THAT INTERVENING EARLIER IS GOING TO BE MORE EFFECTIVE SO WE WANT TO DIAGNOSE IT EARLIER. THAT ISN'T THE CASE STILL. MOST AUTISM IS DIAGNOSED AFTER THE AGE OF THREE STILL AND PARTLY IT'S BECAUSE THE EXPRESSION OF IT HADN'T FULLY FORMED YET IN SOME INDIVIDUALS. THEY HAVEN'T SHOWN THE IMPAIRMENT UNTIL THEY'RE IN SCHOOL SITUATIONS OR OTHER PEER SITUATIONS. IT MAY BE IT IS STILL BIOLOGICALLY UNFOLDING IN SOME CHILDREN UNTIL THEY ARE THREE OR OLDER AS WELL. WE DO KNOW THAT DIAGNOSIS CAN BE MADE USING VERY SPECIFIC METHODS AT AGE TWO OR EVEN YOUNGER, BUT THE STABILITY ISN'T QUITE THERE FOR EVEN TWO YEAR DIAGNOSIS. AND WE ALSO KNOW THAT MOST REFERRALS DO STEM FROM LANGUAGE. THAT'S THE THING THAT BRINGS KIDS IN TO PEDIATRICIANS SAYING MY CHILD'S NOT LEARNING LANGUAGE AND THERE'S BEEN A HUGE MOVEMENT IN THE LAST FIVE YEARS REALLY TO GET PEDIATRICIANS TO ASK THE QUESTIONS ABOUT OKAY, THERE'S LANGUAGE PROBLEMS BUT ARE THEY POINTING, ARE THEY DOING, DRAWING ATTENTION. AND I'M GOING TO GET TO THOSE THINGS IN A MINUTE. SO WHAT DO YOU NEED TO DO TO MAKE A DIAGNOSIS? YOU NEED TO HAVE NOT A TEN MINUTE SESSION WITH YOUR DOCTOR SAYING OH THEY'RE NOT. THAT'S AUTISM. YOU NEED TO HAVE A LOT LONGER EVALUATION THAT INCLUDES A COGNITIVE ASSESSMENT. THAT'S THE POINT I'VE BEEN TRYING TO MAKE IS THAT IF YOU DON'T KNOW A CHILD MENTALLY OR THEIR COGNITIVE LEVEL, YOU CAN'T KNOW HOW TO BASE THEIR SOCIAL AND COMMUNICATION SKILLS. AND ALSO WHETHER SOME OF THEIR INTERESTS ARE APPROPRIATE OR NOT. ADAPTIVE BEHAVIOR, WHAT THEY'RE DOING IN LIFE, WHAT THEY ARE REALLY DOING WITH OTHER KIDS AND OUT THERE IS THEY ARE IMPORTANT TO GAUGE. AND YOU NEED THIS FROM MAIRNLT HISTORY. CHILDREN -- FROM PARENT HISTORY. CHILDREN DO NOT ACT TOTALLY NORMAL IN DOCTOR'S OFFICE OR EVEN A THERAPIST'S OFFICE EVEN AFTER HALF AN HOUR THEY'RE STILL GETTING USED TO IT SO YOU NEED TO GET SOME OF THIS FROM PARENTS. YOU CAN'T RELY ON JUST OBSERVING THE CHILD. ON THE OTHER HAND YOU A ALSO NEED TO OBSERVE THE CHILD. YOU CAN'T JUST TALK TO THE PARENTS, YOU NEED TO SEE IT IN THE CHILD BECAUSE PEOPLE HAVE DIFFERENT EXPERIENCES AND MAY REPORT THINGS DIFFERENTLY. SO SPECIFICALLY A PARENT HISTORY IS NEEDED FOR EARLY DEVELOPMENT BECAUSE AGAIN YOU NEED RIGHT NOW YOU NEED TO SPECIFY THAT THESE THINGS STARTED BEFORE THE CHILD WAS THREE. YOU NEED REPORTS OF PARENT INTERACTIONS. WE LOVE TO HAVE THREE OTHER KIDS IN OUR OFFICE ALL THE TIME BULB WE DON'T SO WE -- BUT WE DON'T SO WE NEED TO HEAR HOW THEY ARE IN SCHOOL AND OTHER SITUATIONS. WE CAN'T EXPECT TO SEE ALL THE REPETITIVE BEHAVIORS OR ROUTINES OR RITUALS IN THE OFFICE. THEY MIGHT HAPPEN AT SPECIFIC TIMES. WE DO HAVE TESTS. THEY'RE NOT TESTS FOR AUTISM BUT THERE ARE TESTS THAT HYPER DIAGNOSE AUTISM. THERE WAS A DIAGNOSTIC INTERVIEW WHICH IS DEVELOPMENTAL HISTORY. THEN THERE'S ALSO THE -- WHICH IS CALLED THE ADOCK AND TRIES TO PROVIDE A NATURAL ENVIRONMENT. IT'S ABOUT 45 MINUTE SESSION THAT A TRAINED CLINICIAN SPENDS WITH A CHILD DEVELOPMENTAL LEVELS AND USES WHAT WE CALL PRESSES AND THAT MIGHT BE TOYS OR CONVERSATION OR SPECIFIC QUESTIONS TO SEE HOW THAT PERSON REACTS AND SCORES THEM BASED ON THE CRITERIA THAT WE ALREADY TALKED ABOUT. SO WE HAVE THIS FOR DIFFERENT AGENTS IN DEVELOPMENTAL LEVELS, SO IT'S CERTAINLY FORMS RIGHT NOW FOR TODDLERS AND IT EXISTS FOR INDIVIDUALS WITH NO SPEECH ALL THE WAY UP THROUGH ADULTS WHO ARE VERBALLY FLUENT. SO NOW LET'S GET, WHAT WE DO WANT TO SEE ON THESE TESTS, A LITTLE COMMERCIAL BREAK. WHICH THERE MIGHT NOT BE MUCH SOUND BUT YOU DON'T NEED THE SOUND BECAUSE YOU SEE THAT SHE IS SHOWING AND SHOWING AND TRYING TO DRIVE BOTH ADULTS IN THE ROOM AND GIVING IT TO THE ADULT AND THEN RESPONDING WITH FACIAL EXPRESSION AND AFFECTS. SO IN FIVE SECONDS, WE CAN SEE HOW MUCH A 12 MONTH OLD IS DOING TO BE, TO USE SOCIAL COMMUNICATION TO BRING PEOPLE IN AND EXPLORE THE ENVIRONMENT THAT SHE MIGHT NOT SAY THIS IS HOW I'M LEARNING BUT IT IS HOW SHE'S LEARNING. AND THEN AGAIN WE DON'T HAVE SOUND BUT WE DON'T NEED IT BECAUSE YOU CAN SEE THAT THIS EXAMINER IS TRYING TO ENGAGE WITH THIS PERSON, HUGGING THEM, GETTING THEM INVOLVED, STICKING THEIR FACE PRETTY MUCH ALMOST SO THAT THEY'RE TOUCHING THE CHILD VERY CLOSE. AND THIS IS WHAT WE CALL JOINT ATTENTION IS WHEN YOU'RE ATTENDING TO AN OBJECT AND THE PERSON AT THE SAME TIME, SO IT'S TRUE THAT ANY CHILD NOT ALL CHILDREN MIGHT NOT RESPOND TO THIS ALL THE TIME. AND SO THAT'S WHY THESE SCRIPTS ARE VERY DIFFICULT. BUT THIS ONE IS ACTUALLY GOOD BECAUSE YOU CAN SEE THAT HE'S SOMEHOW SNAWHOW KNOWING, HE GRABS IT AND DOESN'T KNOW WHAT TO DO WITH THIS HAND SAYING BY A PERSON LOOK LUBE LOOK AND TRYING TO POINT TO SOMETHING. AND SO THIS IS ALREADY SHOWED IN THE SYMPTOMS ALONG THE DEVELOPMENTAL SPECTRUM. THIS IS WHERE WE WOULD CALL A CORE DEFICIT OF AUTISM IN HIS YOUNG AGE. WE SHOULD SEE IT ALREADY BY 12 MONTHS AND THIS CHILD IS ALREADY ALMOST THREE AND WE'RE STILL NOT SAG HIM BE ABLE TO RESPOND TO THIS POINT AND ALSO TO INITIATE IT. SO IF YOU REMEMBER TWO THINGS FROM THIS OR MY PORTION OF IT IS DEVELOPMENT IS EXTREMELY IMPORTANT AND POINTING IS IMPORTANT. NOW WE'RE STUCK. OKAY. AND THEN I JUST WANT TO SHOW THAT YOU CAN HAVE AUTISM AT ORAL STAGES TOO. -- AT OLDER AGES TOO. WE'RE NOT GOING TO SHOW THIS BUT IN THIS CASE IT'S AN INDIVIDUAL WHO IS READING A BOOK AND GETS SORT OF STUCK ON SOMETHING AND STARTS TALKING ABOUT IT AND TALKING ABOUT IT AND TALKING ABOUT IT AND TALKING ABOUT IT AND NOT CHECKING IN WITH THE EXAMINER TO SEE IF THEY'RE INTERESTED TOO. SO NOW THAT WE TALK BOARD OF DIRECTOR WHAT AUTISM IS, WE REALLY NEED TO TALK ABOUT WHAT IT ISN'T BECAUSE IF WE'RE TRYING TO FIGURE OUT IF THERE IS AN EPIDEMIC, HOW THE PREVALENCE IS CHANGING, WE NEED TO MAKE SURE THAT WORE DOING WE'RE DOING A PREFERENTIA L DIAGNOSIS AND NOT JUST CALLING THINGS AUTISM. DIFFERENTIAL DIAGNOSIS IS THE FIRST ONE IS SEVERE INTELLECTUAL DISABILITY WHICH DOES NOT HAVE TO BE ACCOMPANIED BY AUTISM SO WE NEED TO MAKE SURE THAT'S KNOWN THAT YOU CAN HAVE INTELLECTUAL DISABILITY AND NOT AUTISM. AND AGAIN HOW WE FIGURE THAT GETS COMPLICATED BECAUSE PEOPLE WITH INTELLECTUAL DISABILITIES MIGHT HAVE ALL THE CRITERIA WE TALK ABOUT IN TERMS OF HAVING TROUBLE MAKING FRIENDS, NOT COMMUNICATING WELL BUT IT HAS TO BE AGAIN IN LINE WITH THEIR MENTAL DEVELOPMENT. THINGS LIKE SOCIAL PHOBIA, LANGUAGE DISORDERS, ADHD AND JUST TRANSIENT DEVELOPMENTAL ARE THE MAIN DIFFERENTIAL DIAGNOSIS THAT WE NEED TO THINK ABOUT. SO WE DON'T HAVE THE SOUND BUT I STILL THINK IT'S WORTH IT TO SHOW A CHILD. OH, THE SOUND. CAN YOU HEAR IT? GREAT. [UNINTELLIGIBLE] AGAIN, A VERY SHORT SEGMENT BUT YOU'RE SEEING ALL THE THINGS THAT YOU WANT TO SEE AND THIS BY THE WAY IS THE TEST. SO YOU CAN GO HOME AND TELL EVERYONE THE TEST IS NOT REALLY THAT SCARY. SO AGAIN, WE ARE DOING A BIRTHDAY PARTY. THIS CHILD WANTS TO ENGAGE, WE'RE RESPONDING HAVING MAJOR FACIAL AFFECTS WITH RECIPROCITY WITH THE PERSON HERE WANTING TO ENGAGE. EVEN THOUGH I'M NOT SURE IF THIS HAS A PRETTY MAJOR LANGUAGE DELAY BUT IT DOESN'T MATTER WHAT HE'S SAYING I IT'S THE FACT HE'S TRYING TO INTERACT HERE. OKAY. SO NOW I'M GOING TO GET TO THE PART WHERE WE TALK ABOUT HOW THIS ISN'T EASY. SO THIS IS FROM A STUDY THAT HAD ALL THESE DIFFERENT SITES AND USE THE SAME TESTS, ALL THE TESTS I JUST TALKED ABOUT TO DIAGNOSE AUTISM AND YOU CAN JUST SEE THAT THE VARIABILITY OF 50% DIAGNOSED PDMOS AND NOT AUTISM. SO THE WAY WE USE THE CRITERIA AND THE WAY WE DIAGNOSE IT, EVEN IF WE'RE TRAINED IN THE PAST IS NOT CONSISTENT. THIS IS ONLY I THINK IN THE U.S., IN THE U.S. AND POSSIBLY AROUND THE WORLD. SO AUTISM DOES GO THROUGHOUT THE LIFE SPAN. HOWEVER, DIAGNOSIS MAY CHANGE AND THIS STUDY ONLY LOOKED AT WITHIN THE SPECT TRUMP THA SPECTRUM THAT M OST PEOPLE DIAGNOSED WITH IT SAY AUTISM LATER BUT THEY ARE DIAGNOSED WITH -- AND CHANGED TO AUTISM. SOME PEOPLE DON'T GET THE SAME DIAGNOSIS WITHIN THE SPECT TREM AND WE'RE SEEING -- SPECTRUM AND PEOPLE GOING OFF TO SPECTRUM WHEN THEY'RE AGAIN EVALUATED LATER. SO THE OUTCOME IN AUTISM IS TYPICALLY THE NATURE OF THE SYMPTOMS ARE QUITE INTRACTABLE AND PRETTY RESISTENT TO MOST TREATMENTS. I THINK WE'RE GOING TO TALK A LITTLE BIT MORE ABOUT TREATMENT IN A MINUTE. BUT THERE ARE NO TREATMENTS THAT ARE PROVEN TO BE EFFECTIVE FOR THE CORE SYMPTOMS OF AUTISM, THE ONES I ALREADY TALKED ABOUT. THERE'S BEEN A LOT OF TREATMENT STUDIES LOOKING AT ASSOCIATED SYMPTOMS, IRRITABILITY, HYPER ACTIVITY, AGGRESSION, THINGS LIKE THAT. BUT IN TERMS OF THE CORE SYMPTOMS FOR AUTISM, WE HAVE NOT, WE DO NOT HAVE A DRUG. WE DO HAVE BEHAVIORAL INTERVEST INTERVEST -- INTERVENTIONS THAT HAVE SHOWN SOME ABILITY TO CHANGE CORE SYMPTOMS BUT WE HAVE NOT HAD A GOOD MEASURE OF VA SAYITY TO BE iSEVERITY TO LOOK OVER TIME. MOST OF THE STUDIES HAVE LOOKED AT INTELLECTUAL DISABILITY OR EVEN JUST WHAT KIND OF CLASSROOM PLACEMENT A CHILD IS IN AFTER OUTCOME. AND SO THE OLDER STUDIES JUST OUTCOME IS HOW INDIVIDUALS ON THE SPECTRUM LOOK AS THEY GET OLDER ARE QUITE GRIM. I DIDN'T WANT TO SHOW THEM BECAUSE THEY ARE REALLY QUITE GRIM IN TERMS OVER HOW MANY PEOPLE GRADUATE FROM HIGHER EDUCATION OR EVEN HIGH SCHOOL, GET JOBS, ARE ABLE TO LIVE ON THEIR OWN. SO WE REALLY, WE REALLY DON'T KNOW, WE DEFINITELY DO NOT KNOW SINCE THE DSM4 THE CRITERIA THAT I SHOWED THAT HAS BEEN IN USE, THERE'S NOT A STUDY OBVIOUSLY IT'S ONLY BEEN 1994 THAT THIS CAME INTO BEING TO BE ABLE TO SHOW HOW PEOPLE ARE THROUGHOUT THE LIFE SPAN THAT ARE DIAGNOSED NOW THAT THE SPECTRUM HAS BEEN BROADENED. AND THIS IS IN TERMS OF THE INTERAGENCY AUTISM COORDINATING COMMITTEE AND WHAT GOVERNMENT HE WAS ARE TRYING TO DO RIGHT NOW -- GOVERNMENT EFFORTS ARE TRYING TO DO RIGHT NOW, THIS IS A MAJOR MAJOR ISSUE SINCE THE INCREASE IN DIAGNOSIS, INDIVIDUALS ARE GETTING OLDER AND HOW DO WE WORK WITH ADOLESCENCE AND ADULTS. SO I JUST THOUGHT, I THINK I'M NOT GOING TO SHOW THESE. I WILL SHOW THAT JUST IN TERMS OF LANGUAGE DEVELOPMENT A RECENT STUDY DID SHOW THAT IT'S ABOUT A QUARTER FOR EACH WHO DEVELOPED, WHO CONTINUES TO HAVE NO WORDS, HAS WORDS FOR NOT SENTENCES, SENTENCES BUT NOT TOTALLY FLUENT OR IT'S FLUENT. SO WE CAN THINK ABOUT THAT IN TERMS OF OUTCOMES OF LANGUAGE. AND THEN IN TERMS OF OUTCOMES FOR JOBS AND OPPORTUNITIES, THIS IS A HUGE AREA IN NEED AND I'LL JUST GIVE AN EXAMPLE OF A PROGRAM THAT JUST STARTED RIGHT HERE AT NIH THAT IS PROVIDING SOME HELP FOR AT LEAST SOME INDIVIDUALS AND THAT IS A JOB TRAINING PROGRAM WHERE INDIVIDUALS ARE GIVEN A SUPPORTIVE WORKING ENVIRONMENT. THEY'RE GIVEN SPECIFIC COACHING ABOUT HOW TO WORK AND THEN THEY ARE GIVEN HELP IN TERMS OF BEING ABLE TO MOVE TOWARDS A PERMANENT JOB. AND SO THIS HAS HAPPENED RIGHT HERE AT THE CLINICAL CENTER AND VIRUS INSTITUTEVARIOUS INSTITUTES AT NIH A ND IT WAS WORTH MENTIONING RIGHT NOW. I WILL TURN THE TALK OVER TO MORE INFORMATION ABOUT THE HEADLINES WE'VE HEARD AND WHAT IS BEHIND THEM. [APPLAUSE] >> I THOUGHT I WOULD CHOOSE THREE THINGS WE TALKED ABOUT TODAY BECAUSE AS WE HEARD WHAT'S BEEN PULLED OUT OF THE NEWSPAPER WITHIN THE PAST MONTH. IT'S VERY UNUSUAL THING TO HAVE BEEN AT NIH SIGN TITION FOR MORE THAN TWO -- SCIENTIST FOR MORE THAN TWO DECADES AND SUDDENLY TO BE INFAMOUS AND NOT FORTUNATELY FAMOUS AND ANY TIME YOU HERE ATA OR WORK GROUPS, YES, IT'S OUR FAULT. AUTISM IS EPIDEMIC. WE'VE BEEN HEARING THIS NOW FOR MORE THAN A DECADE EVERY ARE TIME CDC PUBLISHES ANOTHER SET OF RESULTS THE RATE HAS GONE UP. YOU ALREADY HEARD FROM DR. THERM HOW DIFFICULT IT CAN BE WITH THE DIAGNOSIS AND WE CAN GO INTO DETAILS OF THOSE STUDIES SO THAT YOU CAN BEGIN TO HELP US REALLY GET THINKING ABOUT RESPONSIBILITY OF SCIENCES IN INTERPRETATION OF THEIR DATA. AND I JUST CHALLENGE YOU ALL NO MATTER WHAT YOU'RE DOING FOR YOUR FULL TIME JOB BUT THAT'S A REALLY IMPORTANT THING. THE HEADLINES ARE SCREAMING ONE IN 54 BOYS IS NOW AFFECTED. IT'S BECOME AT THE POINT THAT IT'S TWO AUTISM WITH ONE BOY, THEY FINALLY GET IT BUT MAYBE THERE'S A PROBLEM WITH COUNTING BUT APPARENTLY NOT YET. AND THIS PAST WEEK, THE HEADLINE WAS RISING AUTISM RATE WITH PATERNO BEASTMATERNAL TURN OBESITY AND THE EPIDEMIC WAS CROSSING AND THIS WAS GOING TO BE A BIGGER PROBLEM. THE AUTISM WORD IS ACTUAL ME BEING FOUGHT OVER THOSE DSM4 AND 5 CRITERIA WORKERS FOR NEURO DEVELOPMENT DISORDERS OF THE DSM5 TASK FORCE. ACTUALLY HAS A NEW YORK STATE SLATELEGISLATOR WHO HAS PROPOSED THE LAW BAN USE OF THE DSM5 IN THE STATE OF NEW YORK AND I'LL SHARE WITH YOU HOW THAT ALL CAME ABOUT. YOU HAVE TO LAUGH BECAUSE OTHERWISE YOU'RE SCREAMING. THE SUBHEADLINES WAS SKILLED SERVICES THAT IS NOW AT 6 R5%. THAT'S WHAT MOST PARENTS ARE THINKING. [INDISCERNIBLE] THE FINAL ONE IS [INDISCERNIBLE] SHOW OF HANDS HOW MANY PEOPLE KNOW SOMEBODY WHOSE CHILD IS AWE TITION PARTICULAR. PARTICULAR-IS AUTISTIC. HOW MANY WHO ARE IN COLLEGE JUST STARTING OUT KNEW SOMEBODY WHO WAS AUTISTIC. [INDISCERNIBLE] HOWEVER IT WAS THE AS COMMON AND IT CERTAINLY WASN'T SOMETHING WE WERE SHARING CONSTANTLY. IN THE 1980'S IT WAS DEFINED AS A RARE DISORDER [INDISCERNIBLE] JUST REMEMBER THAT NUMBER SIX IN 10,000 ABOUT THREE QUARTERS TO 1,000 [INDISCERNIBLE] WHAT HAPPENS IN 1992 IT'S NOT ON THIS SLIDE BUT 1992 THE DEPARTMENT OF EDUCATION ALLOWED AUTISM AND AUTISTIC SYMPTOMS TO BE [INDISCERNIBLE] [INDISCERNIBLE] TREATMENT TARGET OR SERVICES PROVISION TARGET, THE STATE OF CALIFORNIA REQUIRED A FULL BLOWN DIAGNOSE OF AUTISM. SO WHEN DR. THERM SHOWED THOSE 12 SITES THAT HAD 100% AUTISM MONEY IS PROBABLY SWRR IN CALIFORNIA. THEY DON'T DIAGNOSE APD OR AS -- AASAS AS ASBERGERS. SUDDEN THE RATE HAS EXPLODED EXIST CONTINUED TO INCREASE EVERY TIME. ASOMEBODY DID NOT HERE A WEEK AND-A-HALF OF COVERAGE OF THE LATEST CDC DATA AND HOW AUTISM RATES HAD INCREASED YET AGAIN. THE LAST TIME THEY REPORTED IT IN 2009, THE RATES WERE ACTUALLY ABOUT THE SAME. ONE IN 58 VERSUS ONE IN 54. MIGHT BE THE MARGIN OF ERROR. IN THE EIGHT YEARS THE STUDIES HAVE BEEN NOW THE DATA REPORTED FOR 2012 AND 2008. SO THEY'RE ALWAYS FOUR YEARS BEHIND. THEY'RE LOOKING AT COHORT OF EIGHT YEAR OLDS IN THE SURVEY IN 2000 THEY HAD SIX SITES AS OPPOSED TO THE 14 USING NOW AND THEY HAD -- SO THAT'S TEN TIMES HIGHER THAN IT HAD BEEN REPORTED IN THE 1980'S. NOW IT'S UP TO 11.3, ALMOST TWICE AS MANY? 20-- TWICE AS MANY IN -- 4.8 TO 21.3. THIS IS THEIR ERROR -- NOT ERROR, THIS IS THE DIFFERENCES IN REPORTING RATES ACROSS THE 14ADAM AUTISM DEVELOPMENTAL DISABILITY MONITORING SITES NETWORK. THEY HAVE 14 SITES. THEY ARE OBTAINING SCHOOL RECORDS AND MEDICAL RECORDS AND WHEN YOU ACTUALLY READ THE MMWR REPORT THAT CAME OUT MARCH 30TH, THE NUMBER OF SITES WHO HAD ACCESS TO PRIMARY MEDICAL RECORDS WAS MINIMAL. THEY WERE DEPENDING ON MEDICAL RECORDS THAT HAS BEEN FORWARDED TO THE SCHOOL. THE SCHOOL RECORDS ARE OBTAINED FROM USUALLY, EXCUSE ME NOT USUALLY, THEY ARE OBTAINED IN SPECIAL EDUCATION SERVICES PROVISIONS FOR WHICH YOU NEED TO HAVE AN IEP OR INDIVIDUAL EDUCATIONAL PLAN. FOR ANY WHO KNOW ANYTHING ABOUT PEDIATRICS AND TAKING CARE OF KIDS AND MAKING SURE KIDS GET SERVICES THEY NEED IN THE SCHOOLS THE IEP'S ARE WRITTEN BY THE SCHOOL PSYCHOLOGISTS, THE PARENT AND THE TEACHERS IN AN EFFORT TO JUSTIFY THE SERVICES THAT THEY NEED TO PROVIDE TO THAT CHILD. SO IF YOU HAD A CHILD WITH COMMUNICATION DEFICITS, WHO IS NOT ABLE TO PLAY WELL WITH PEERS OR EVEN HAD ADHD AND IS NOT PLAYING WELL WITH PEERS, DOES NOT PLAY WELL WITH PEERS IS GOING TO APPEAR BUT IT MIGHT BE FOR 14 DIFFERENT REASONS. THE PROBLEM IS IF YOU ARE EXTRACTING THOSE RECORDS, NIGHT LOOKING AT THE CHILD FACE TO FACE, LOOKING AT THE KINDS OF THINGS, THAT LITTLE CHILD THAT WAS SO EXCITED ABOUT PLAYING SO NICELY WITH THE EXAMINER THAT DR. THERM SHOWED US. IF HE WAS FIVE YEARS OLD BECAUSE OF HIS LANGUAGE DELAY HE'S GOING TO MEET THE CRITERIA IN THE CDC STUDY FOR AN AUTISM SPECTRUM DISORDER. SO THAT'S THE BIGGEST PROBLEM WE HAVE TODAY IS WE DON'T ACTUALLY KNOW WHAT IS HAPPENING TO RATES OF AUTISM AS IT TRADITIONALLY HAS BEEN DESCRIBED. WE'LL TALK A LITTLE BIT MORE ABOUT WHY DID THE DSM5 CAVE, WHY ARE WE MOVING TO A SINGLE SPECTRUM DIAGNOSIS RATHER THAN TRYING TO FORCE PEOPLE TO REALLY DEAL WITH THE ISSUES AROUND AUTISM BUT YOU SAW A BIT OF IT IN THE DATA DR. THERM SHOWED YOU. IT'S VERY DIFFICULT TO DRAW THOSE LINES. SO THE OVERALL STATEMENT PREVALENCE OF AST WAS 11.4 PER 1,000 IN THIS LATEST SURVEY FOR EIGHT YEAR OLD CHILDREN OR 1 IN 88. 1 IN 54 BOYS AND INTERESTINGLY 1 IN 252 GIRLS. THAT HAS NOT CHANGED ALMOST AT ALL IN THE PREVALENCE THAT'S SUPPOSED TO INCREASE BY 78%. WE NEED TO ASK THE CDC WHY THAT IS HAPPENING. YES, GIRLS ARE SOMETIMES MISSED WHEN THEY HAVE AUTISM SPECTRUM DISORDERS. ON THE OTHER HAND BECAUSE OF THE CONCERN THAT THE DIFFERENTIAL DIAGNOSIS ARE NOT BEING APPROPRIATELY EXCLUDED ARE THE SCHOOLS TAKING CHILDREN WHO HAVE LEARNED DISABILITIES AND HDAD AND GIVING THEM AN AHD DIAGNOSIS IN ORDER TO PROVIDE MORE SERVICES. WE HAVE NO WAY TO LOOK AT THOSE DATA AND TELL YOU. THE OTHER FACTOR THAT YOU HAVE TO THINK ABOUT IS THE FACT THAT THE PREVALENCE RATES VARY ALMOST FIVE FOLD BETWEEN THE LOWEST PREVALENCE AND THE HIGHEST PREVALENCE. GRANTED THE LOWEST PREVALENCE RATES ARE IN ALABAMA AND THE POORER STATES THEY ARE ALSO LORA MONK BLACKS AND POOR COMMUNITIES. HOWEVER, THE VDC' CDC'S CLAIM IN SITES SUCH AS UTAH WHERE THEY HAD A RATE OF 21.2 FOR THEIR TOTAL PREVALENCE BUT NOTICE THAT THAT WAS BASED ON A TOTAL OF 45 CHILDREN WHO WERE DIAGNOSED TO HAVE AUTISM SPECTRUM DISORDER BECAUSE THEY ONLY DID IT IN ONE IN ONE SCHOOL. 2000 EIGHT YEAR OLD CHILDREN WERE SURVEYED AND THEY FOUND 45ASD. THAT RAISES THEIR TOP CHANGE OF THE RELUNS T PREVALENCE TO 21.2 WHERE ALABAMA IS 1.8. WE HAD A CONVERSATION WITH ONE AT AUTHORS HO AWE AUTHORS OF THIS PAPER AN D THEY ARE VERY HONEST LOOKING AT THE DATA AND CONCLUDING IT IS AN UNDER REPORTING IN ALABAMA SITES RATHER THAN AN OVERREPORTING IN PLACES LIKE YEW VAWRKS MY FAVORITE HAS ALWAYS BEEN NEW JERSEY BECAUSE THE ADDM SITE IS IN BRICK TOWNSHIP AND BRICK TOWNSHIP IS ABSOLUTELY FAMOUS COUNTRY WIDE FOR PROVISION OF AUTISM SERVICES THAN ANY OTHER SCHOOL DISTRICT IN THE COUNTRY CAN PROVIDE. WOULD THE BE POSSIBLE THAT PERHAPS PEOPLE MOVED THERE. YES. AND IT DOESN'T DECREASE THE REALITY OF THOSE CHILDREN'S AUTISM SPECTRUM DISORDER BUT IT DOES HAVE A TREMENDOUS IMPACT ON OUR PERCEPTION THAT THERE IS RISING RELUNS. SO THE EASIEST EXPLANATION ARE THERE ARE MORE CASES IN THIS TALK LAST YEAR HE SAID THEY ARE MORE CASES OF AUTISM SPECTRUM DISORDERS. IT IS ABSOLUTELY TRUE THAT MORE CHILDREN ARE BEING DIAGNOSED WITH THIS DISORDER. THE QUESTION IS, ARE THERE ACTUALLY MORE NEW CASES, ARE THERE THINGS WE USED TO THINK OF AS A DIFFERENT DISORDER PREVIOUSLY. HAVE WE CHANGED THE DEFINITION TO BROADEN IT SO THAT THAT QUESTION OF IMPAIRMENT AND REALLY THE SYMPTOMS GETTING IN YOUR WAY OR IS THIS PART OF A OVERALL PHENOMENA. ONE OF MY ISSUES HAS BEEN IF YOU HAVE A SEGGANT ENOUG SIGNIFICANT ENOUGH RETARDATION THAT'S SO PROFOUND THAT YOU CAN'T COGNITIVELY HAVE THESE KIND OF NORMAL INTERACTIONS SHOULD YOU BE EXCLUDED FROM THE SPECTRUM AND THE ANSWER HAS BEEN NO. THAT YOU CAN HAVE BOAST DIAGNOSIS BECAUSE THEY BOTH -- HAVE BOTH DIAGNOSIS. THE DIAGNOSTIC ASSESSMENTS HAVE IMPROVED. I WILL SAY THE AWARENESS HAS INCREASED AND THAT'S IN LARGE PART BECAUSE OF THE NATIONAL CAMPAIGN TO INCREASE AUTISM AWARENESS. AUTISM SPEAKS IN THE AMERICAN ACADEMY SPEED TRICKS. THE -- PEDIATRICS. THE QUESTION IS NOT WHETHER OR NOT AWARENESS HAS BEEN APPROPRIATELY SPECIFIC. AND THE FACT THAT AN AUTISM DIAGNOSIS DOES INCREASE THE SERVICES ABLE TO BE PROVIDED TO THAT CHILD IS HUGE. I START TO SOUND A LITTLE CRANKY AND I'M NOT, IT'S JUST I'VE LEARNED FROM SOME OF THE WEST DEVELOPMENTAL -- BEST DEVELOPMENTAL FOLKS IN THE COUNTRY TO GIVEN A CHILD AN ASD DIAGNOSIS WHEN THEIR ACTUAL PROBLEM IS A LEARNING DISABILITY AND ADHD OR OVERALL INTELLECTUAL DISABILITY IS NOT DOING THEM A FAVOR. BECAUSE YOU'RE FOCUSING ON THE WRONG SET OF SYMPTOMS AND YOU'RE TRYING TO FOCUS ON AN AREA OF IMPAIRMENT THAT MAY NOT BE THEIR ENVIRONMENPRIMARY DEFICIT. THAT'S WHERE MY CONCERN LIES. YOU CAN GIVE EVERYBODY THE DIAGNOSIS IF IT ENDED UP BEING APPROPRIATE TO THAT CHILD AND MOST HELPFUL TO THAT INDIVIDUAL. AND THEN FINALLY THE DIFFERENCE IN METHODOLOGIES. IN OCTOBER OF 2009, HUGE OVER THE STAGGERING RATES OF ONE IN 58 WHO ACTUALLY CAME OUT FROM THE CDC SLIGHTLY LATER AND WAS SIMILAR RIGHTS AND ONE IN 91 CHILDREN OVERALL SO VERY PRODUCT TO WHAT'S BEEN REPORTED. THIS WAS DONE BY A TELEPHONE SURVEY. WE HEARD THIS IS A LIFE LONG NO DEVELOPMENTAL DISORDER WITH CORE DEFICITS IN SOCIAL COMMUNICATION AS WELL AS THE ADDITION OF RESTRICTED REPETITIVE BEHAVIORS AND YET 40% OF THE CHILDREN WERE REPORTED TO HAVE LOST THEIR DIAGNOSIS WITHOUT ANY KIND OF INTERVENTION. AND YOU HAVE TO AT THAT POINT SAY WHICH WAS THE PROBLEM WITH THE SURVEY. IT WAS A TELEPHONE SURVEY AND THE QUESTION INCLUDED ALL OF THE LISTED AUTISM DIAGNOSIS. SO THEY WOULD ASK A MOM HAS YOUR CHILD EVER BEEN DIAGNOSED WITH AUTISM, PERVASIVE DEVELOPMENTAL DISORDER NOT SPECIFIED ASPERGER'S DISORDER OR OTHER SPECTRUM. AND THEY ARE LIKE I HEARD DEVELOPMENTAL DISORDER, YES. THEY COME BACK AT THE END OF THE TIME THEY DIDN'T V THE CDC STUDIES WE'VE ALREADY TALKED ABOUT REVIEW MEDICAL RECORDS AND SCHOOL RECORDS. THE PROBLEM IS THEY USE KEY WORDS. THEY HAVE AN INCREDIBLY COMPLEX AALGORITHM, THEY DO A CAREFUL JOB THE PROBLEM IS THE ASCERTAINMENT IS JUST NOT THERE TO BE ABLE TO TELL WHAT IS THE MEANING BEHIND THOSE KEY WORDS THAT THEY'RE CODING. THEY ALSO DON'T EVER CONFIRM CASENESS, THE RATIONALE FOR THIS IS THE ADDM MONITORING SITES ARE AN ONGOING EFFORT TO IDENTIFY THE CASES THROUGH SPECIAL EDUCATION SERVICES AND THEY ARE ALWAYS FOUR YEARS BEHIND SO THEY WOULD HAVE TO BE LOOKING FOR 12 YEAR 0E8DZ T OLDS TO CONFIRM WHAT THEY ARE SEEING IN TWO YEAR OLDS. THEY CAN SKIP THE SURVEY AND INTOINTO SAMPLING OF SITES AND ASK THE QUESTION IS ALABAMA UNDER COUNTY OR ARE NEW JERSEY AND UTAH OVERCOUNTING. IF WE YOU ZOOM THE RATE ASSUME THE RATES W E STILL HAVE THEY IDEA WHAT AUTISM RATE IS. HERE'S A STUDY THAT NEVER MADE THE HEADLINES. A SIMILAR STUDY HAS BEEN REPORTED HERE IN THE UNITED STATES. THAT IS THE FACT IF YOU USE THIS SAME TECHNOLOGY AND THE SAME METHODOLOGY RATHER AND YOU GO IN AND YOU COUNT BY KEY WORDS OR EVEN BY DIAGNOSIS THAT THE RATES IN ADULTS ARE COMPARABLE TO WHAT ARE NOW BEING REPORTED IN CHILDHOOD. SO WE'VE BEEN FOCUSING ON THIS TERRIBLE EPIDEMIC AMONG YOUNG CHILDREN IN THE UNITED STATES WHICH LEADS US INTO VERY DIFFERENT PATHWAY OF TRYING TO FIGURE OUT ETIOLOGY AND PATHOGENESIS OF THIS DISEASE THAN IF IT'S A RELATIVELY STABLE PHENOMENON OR RECOGNIZING IT MORE DIFFERENTLY. SO THE REPORT IN THE ADULT PSYCHIATRIC MORBIDITY SURVEY IN ENGLAND DEMONSTRATED THAT THERE WAS 1% OF THE ADULT POPULATION HAD AUTISM SPECTRUM DISORDER AND MET FULL CRITERIA FOR AUTISM, PPD OR ASPERGER DISORDERS. AND AT THE SAME TIME THEY DID A STUDY IN CHILDHOOD AND THE PREVALENCE RATES WERE EXACTLY THE SAME. SO IN ENGLAND THERE WERE NOT THESE DIFFERENT RISING RATES AS THE POPULATION WAS AGING. HOWEVER, IF YOU HAVE 1% OF THE POPULATION IN ADULTHOOD AS DR. THERM ALREADY TOLD US, WE NEED TO BE THINKING HOW TO DEAL WITH THIS AND DELIVER SERVICES TO ADULT INDIVIDUALS WHO ARE PROBABLY NOT GOING TO BE ABLE TO FUNCTION OPTIMALLY INDEPENDENTLY. WE TALKED A LITTLE BIT ABOUT CHANGES OF DEFINITION AND THAT'S GOING TO LEAD US INTO OUR NEXT SOCIETY HEADLINES AND THE BOTTOM LINE IS IT IS A BEHAVIORAL SYNDROME DEFINED IN THE DSM5. I HAVE SPENT MOST OF MY RESEARCH CAREER STUDYING COMPULSIVE DISORDER ANOTHER PSYCHIATRIC DISORDER DEFINED IN THE DSM. IT'S REALLY EASY TO DIAGNOSE OCD. THE PERSON DOESN'T HAVE IT AND THEN THEY GET IT AND YOU CAN TELL THE DIFFERENCE BETWEEN WHEN YOU DIDN'T HAVE IT AND THEN WHEN YOU DO. BY THE FACT THAT YOU NOW HAVE THESE OBSESSIVE INTRUSIVE THOUGHTS OR YOU HAVE THESE COMPULSIVE RITUALS THAT ARE TIME CONSUMING INTERFERING AND CAUSING A GREAT DEAL OF DISTRESS. HOW DO YOU ACCURATELY DIAGNOSE A DISORDER IN AN INDIVIDUAL WHEN IT'S A DEFICIT, WHEN IT'S A FAILURE TO MEET CERTAIN MILESTONES AND YOU HAVE TO MAKE A JUDGMENT ABOUT WHETHER OR NOT MEETING THAT MILESTONE IS CRUCIAL TO THEIR ONGOING FUNCTIONING. THE OTHER THING ABOUT ASP IS WITH ALL PSYCHIATRIC DIAGNOSIS, PDDNOS IS THE GARBAGE CAN, THE WASTE BASKET TERM THAT YOU'RE SUPPOSED TO USE ON THE IF THEY DON'T FULLY MEET AUTISM OR ASPERGER'S SYNDROME. IN MANY PLACES MORE THAN HALF OF THE CASE ARE GIVEN A DIAGNOSIS OF PPDNOS. THAT'S A MISTAKE THAT HAPPENED IN DSM3R WHERE A VERY GOOD GRAMMARIAN TOOK OUT THOR, AND/OR THE OR, AND/OR AND YOU SUDDENLY HAVE SOCIAL DEFICITS. SO YOU COULD TAKE OUT THE LANGUAGE DEFICITS AND YOU DIDN'T HAVE TO RESTRICT REPETITIVE DISORDERS OR THE WHOLE SPECTRUM OF AUTISM DISORDERS. CLINICIANS HAVE CONTINUED TO HOLD ON THIS. IN OUR DSM5 FIELD TRIALS ONE OF THE TRAINING PHYSICIANS DETERMINING HOW WELL ART CRITERIA WAS GOING TO WORK WROTE A COMMENT THAT HIS PATIENT DID NOT MEET THE DSM5 CRITERIA. HE HAD NOT MET DSM4 EITHER BUT HE KNEW HE HAD AUTISM OR HE GIVE HIM THE DIAGNOSIS. IT'S PRETTY HUMBLING AND I THINK IT'S EXACTLY THE SITUATION IS IF YOU'RE DEPENDENT ON A CLINICAL SECOND HAND DIAGNOSIS AND YOU DON'T HAVE A LABORATORY TEST TO PROVE THAT YOU'RE GOING TO HAVE TO DEPEND ON THE GOODNESS OF YOUR FIT. SO THESE AUTISM WARS I THINK I ALREADY SOUNDED LIKE I'M AT BATTLE SO I APOLOGIZE FOR THAT. BUT THE BIGGEST PROBLEM HERE IS THAT THE FAMILIES AND THE AFFECTED INDIVIDUALS ARE THE COLLATERAL DAMAGE IN THIS WAR. BECAUSE THEY'RE THE ONES READING THESE HEADLINES AND THEY ACTUALLY BELIEVE THAT THE DSM5 TASK FORCE SET OUT TO NIP THE EPIDEMIC IN THE BUD OR TO SLASH SERVICES AND HELP OUT THE DEPARTMENT OF EDUCATION BY MAKING THEIR JOB EASIER. THERE ACTUALLY WAS A HEADLINE IN THE "NEW YORK TIMES" AN ARTICLE THAT WAS THEN PICKED UP ON THE AP AND THE ACTUAL HEADLINE WAS PROPOSED DSM5 UNITE YEAH WITH -- CRITERIA WITH 60% IN INDIVIDUALS OF AUTISM. IF I WERE A PARENT I WOULD BE VERY VERY WORRIED AND YOU CAN SEE WHY THEY ARE WRITING, PUTTING PETITIONS INTO THE DSM AS WELL AS SENDING JUST COUNT LESS NUMBERS OF E-MAILS. THE "NEW YORK TIMES" ARTICLE CAME OUT IN JANUARY AND REPORTED THAT RESULTS WOULD BE PRESENTED IN MAJOR MEDICAL MEETING BY A DISTINGUISHED INVESTIGATOR. THE MAJOR MEDICAL MEETING WAS THE ICE LANDIC MEDICAL ASSOCIATION WINTER MEETING. JANUARY IN ICELAND. NOT ONE OF THE MAJOR MEETINGS MOST OF US GO DO. WE ACTUALLY TRIED TO CALCULATE IT. THERE ARE 250,000 PEOPLE IN ICELAND, SO THEY PROBABLY HAVE MAYBE TWO SITE JOB PSYCHIATRISTS AND POSSIBLY A COUPLE DOZEN INDIVIDUALS WITH AUTISM. SO THE THINKING BEHIND THIS BEING A MAJOR MEETING FOR THESE RESULTS IS SOMEWHAT LACKING. BUT IN THAT ARTICLE THEN KERRY TALKED ABOUT THE 35% OF HIGH FUNCTION ASD CASES WOULD BE MISSED. NORMAL INTELLIGENCE, THE ASPERGER'S INDIVIDUALS WHO HAVE VERBAL SKILLS BUT THEY LACK SOCIAL COMMUNICATIONS SKILLS AND THEY HAVE RESTRICTIVE OR REPETITIVE BEHAVIORS. THAT AS I ALREADY MENTIONED THAT TURNED AROUND, FLIPPED AROUND SO IT BECAME 65% WOULD BE MISSED AND THE NEXT PART OF THE TELEPHONE GAME WAS THAT IT WASN'T JUST HIGH FUNCTIONING PASASAS -- AS AS AS PERGERS IS TRYING TO TAKE PAPER CAME OUT IN THE AMERICAN ACADEMY OF PSYCHIATRY, I'M VERY CRANKY ABOUT THIS BECAUSE SEVERAL OF THE MEMBERS OF OUR WORK GROUP REVIEWED THE PAPER ALL THREE OF THEM FELT IT WAS FATALLY FLAWED BECAUSE OF THE LACK OF THE ABILITY TO USE APPROPRIATE DATA. WHAT THEY USED WAS FIELD TRIAL DATA FROM DSM4 SO THEY WERE COMPARING THE DSM3R CRITERIA WITH THE PROPOSED DSM4 CRITERIA JUST IN OUR FIELD TRIALS THEY THEN TAKE AND RECORD HOW MANY OF THE PATIENTS MET THE CRITERIA WITHIN THE DSM4. THEY DIDN'T KNOW WHAT THE CRITERIA WOULD BE FOR DSM5. SO IT WOULD BE IMPOSSIBLE FOR THEM TO ASCERTAIN WHETHER OR NOT THOSE PEOPLE, CHILDREN HAD THOSE SYMPTOMS. THEY DO ACKNOWLEDGE THIS AS A LIMITATION IN THE DISCUSSION BUT THE DATA WEREN'T AVAILABLE TO DIRECTLY ASSESS THE DSM FIVE CRITERIA. BUT AGAIN JUST A GENERAL SCIENTIFIC WARNING, DON'T EVER BELIEVE IN THE ABSTRACT OF THE PAPER BECAUSE THIS ABSTRACT CONCLUDES THE REVISED CRITERIA TO SUBSTANTIALLY ALTER THE COMPOSITION OF THE AUTISM SPECTRUM, REVISED CRITERIA IMPROVED SPE FISTY THAT EXCLUDES THE PORTION OF COGNITIVE INDIVIDUALS WITH THOSE WITH ASD AND OTHER AUTISTIC DISORDERS. IN FACT THEY STATED THAT ONE THIRD WILL BE MISSED. THEIR CHARGE WAS WE WANT TO MAKE THIS DIAGNOSIS MORE SPECIFIC. WHEN WE STARTED THE WORK FIVE YEARS AGO AS A WORK GROUP ONE OF THE QUESTIONS IS CAN WE IMPROVE SPECIFICITY JUST FOR THE REASONS I'M TALKING TO YOU ABOUT. IF YOU HAVE A CHILD WITH A GLOBAL DEVELOPMENTAL DELAY WITH THE DIAGNOSIS OF SPECTRUM DISORDER YOU'RE MISSING PART OF THE ICEBERG AND ONLY DEALING WITH THE TIP. THAT'S THE SPECIFICITY WE WERE TRYING TO ADDRESS. SO THE AUTHORS ASSUMED WE WERE TRYING TO ADDRESS THE SPECIFICITY BETWEEN A CHILD WITH AUTISM AND A TYPICALLY DEVELOPING CHILD. ALSO AN IMPORTANT DISTINCTION BUT ONE WHICH IS ACTUALLY DETERMINED BY IMPAIRMENT IN THE PRNS OPRESENCE ON IMPACT OF FUNCTIONING. IF YOU PUT THE DSM4 AND DSM5 SIDE BY SIDE THESE AUTHORS CONCLUDED THAT OURS ARE LESS SENSITIVE AND MUCH MORE SPECIFIC. I APOLOGIZE BECAUSE THE TEXT IS TOO SMALL TO READ BUT I CAN PROMISE YOU THAT THE OFFICE IS ACTUALLY TRUE. LET'S JUST TAKE THE LAST ONE. YOU HEARD FROM DR. THERM IN DSM4 YOU HAVE TO HAVE SYMPTOMS PRESENT AT THE AGE OF THREE. EVEN FOR ASPERGERS DISORDER, YOU HAVE TO HAVE EARLY MANIFESTATION OF COMMUNICATION DEFICITS OR RESTRICTIVE OR REPETITIVE BEHAVIOR. IN THE DSM5 PROPOSED CRITERIA OUR COMMITTEE DETERMINED THAT WAS MUCH TOO RESTRICTIVE BECAUSE THE CHILD MIGHT HAVE BEEN RAISED IN A RELATIVELY SOLITARY ENVIRONMENT NOT BEING IN DAY CARE. YOU WOULDN'T ACTUALLY VAN ABILITY TO KNOW WHAT WHAT HIS PEER RELATIONSHIPS WERE LIKE AND MAY NOT MANIFEST SYMPTOM. THE ONE WE KEPT THINKING ABOUT IS THAT CHILD WITH A HIGH ENOUGH IQ THEY CAN SORT OF PASS UNTIL THEY GET INTO JUNIOR HIGH AND THEN JUST THE SPEED AND THE COMPLEXITY AND THE SOCIAL INTERACTION IS COMPLETELY YOUR WHELM -- OVERWHELMING THEY GET OFF TRACK AND END UP WITH SIGNIFICANT PROBLEMS. THE DSM5 CRITERIA IS SYMPTOMS MUST BE PRESENT IN EARLY CHILDHOOD BUT MAY NOT BECOME FULLY MANIFEST UNTIL SOCIAL DEMANDS EXCEED CAPACITY. THAT MIGHT BE THE ADULT WHOSE GOTTEN AWAY WITH GIVING THEIR SOLILOQUY ABOUT POKEMAN CARDS WHEN THEY WERE IN YOU'RE HIGH IT'S SO CUTE BUT BY THE TIME THEY GET INTO THE WORK PLACE AND THEY CAN'T LET GO OF IT IS NO LONGER FUNCTIONAL. IN YOU DO AGAIN COMPARISON SIDE BY SIDE IT'S VERY CLEAR THAT THE CHARGES AREN'T JUSTIFIED AND THE FIELD TRIAL DATA FROM ART, FIELD TRIAL WILL PROVE THAT, THAT YOU CAN'T SHOW THOSE WITH YOU YET BECAUSE THEY'RE STILL BEING ANALYZED BUT A PRELIMINARY ANALYSIS SHOWED THAT WE ACTUALLY DID NOT MEET OUR GOAL OF BEING MORE SPECIFIC AS WE ACTUALLY BROUGHT IN ABOUT FIVE PERCENT MORE CASES THAN THE DSM4. HOWEVER WE DO HAVE HAVING THAT IS A HUGE ADVANCE IN TERMS OF THINKING HOW TO COMPARE RESEARCH STUDIES ACROSS DIFFERENT SITES. AND THAT IS THE FACT THAT IN DSM5 WE'RE PROPOSING PAN EXTENSIVE USE OF SPECIFIERS. A SINGLE BIG BUCKET OF AUTISM SPECTRUM DISORDERS BUT WITHIN THAT THE PERSON SHOULD SPECIFY WHAT THEIR IQ IS, WHAT THEIR LEVEL OF FUNCTIONING IS AND WITHIN EACH OF THE CRITERIA FOR SOCIAL COMMUNICATION FIXATED INTERESTS IN REPETITIVE BEHAVIORS, WE HAVE AN INDEPENDENT ASSESSMENT OF SEVERITY. SO WITHIN SOME OF THE FIVE BEHAVIOR ANALYSIS, THE BEHAVIORAL INTERVENTIONS, SOME OF THEM ARE QUITE GOOD FOR THE RESTRICTIVE REPETITIVE BEHAVIORS AND THOSE MIGHT BE MINIMIZED BECAUSE OF THE TREATMENT THEY'VE RECEIVED OR PERHAPS YOU HAVE SUPPORTS IN PLACE THAT KIM PROVE THE PERSON'S ABILITY TO COMMUNICATE IN SOCIAL SETTINGS. BUT YOU ARE ALLOWED TO CONSIDER HOW THAT PERSON WOULD FUNCTION WITHOUT THAT. AND THEN TO RATE THOSE SEPARATELY. SO I GUESS MY QUESTION FOR YOU AND WATCH FOR THIS PROBABLY SIX MONTHS FROM NOW IS WHEN THE PAPER WILL BE PUBLISHED JUST TO SEE HOW BIG THE HEADLINES ARE WHEN IT'S SHOWN THAT THE DSM5 ACTUALLY DOESN'T MIX THE EPIDEMIC AND THE BUGS. SO LET'S MOVE ON TO THE LASTS AREA AND THAT IS THE SCIENTIST LINK NEW GENES TO AUTISM. I APOLOGIZE IF I SOUND VERY CYNICAL ABOUT THIS WHOLE PRESENTATION. WE'LL GO BACK TO THE VIDEOS AND WE CAN ALL SMILE AT THE WONDERFUL CHILDREN. BUT IT HAS BEEN A RATHER SOAK RING THING TO BE -- SOBERING THING TO BE GOOD FRIENDS OF FAMILIES WHO HAVE AFFECTED CHILDREN AND TO SEE WHAT SCIENCE IS DOING TO THOSE FAMILIES AND TO THEIR SORT OF ROLLERCOASTER OF HOPE AND DASHING OF THOSE HOPES AS EACH WEEK A GROUP IS ISSUING A PRESS RELEASE AND REPORTING THAT THEY HAVE FOUND ANOTHER CASE, ANOTHER CAUSE. WE'VE GONE FROM -- CONCLUDING THAT THIS WAS THE RESULT OF REFRIGERATOR MOTHERS AND SIGH COMPANY -- PSYCHO ANALYSTS WERE TRYING TO TREAT THE MOMS COLD IN AN UNRESPONSIVE MANNER TO NOW BLAMING THE MOMS FOR BEING OBESE OR THE MOMS AND DADS FOR A GENE THAT WHEN WE LOOK AGAIN THREE MONTHS LATER IN A DIFFERENT POPULATION, OH IT'S ACTUALLY BENIGN. SO AS NEW TECHNOLOGIES ARE DEVELOPED WE HAVE NEW FINDINGS AND THAT'S ABSOLUTELY IMPORTANT IN APPROPRIATE AND ONE OF THE BEST THINGS THAT'S HAPPENING IN THE GENETIC RESEARCH ON AUTISM IS THAT IT'S FINALLY COMING TO BE MATURE ENOUGH THE PEOPLE UNDERSTAND IT ISN'T GOING TO BE THAT HEADLINE NEW GENE BUT RATHER IT'S GOING TO GIVE US INFORMATION ABOUT THE PATHWAYS AND THE NETWORKS THAT ARE INVOLVED AND THE PROTEINS AND PERHAPS NEW TREATMENT TARGETS FOR THESE. NEW POPULATIONS ARE STUDIED, THAT'S WHERE WE'RE HAVING TERRIBLE PROBLEMS. IF YOU ARE IN A GENETICS CLINIC THAT SPECIALIZES WHEN WE OPEN AND THAT'S WHAT YOU'RE SEEING IS WHEN WE OPEN SYNDROME THEN YOU HAVE THAT PERSPECTIVE AND SUDDENLY THAT GENE IS CAUSING AUTISM. BUT YOU HAVE TO REMEMBER THEY CAME THERE BECAUSE THEY HAVE A CHOLESTEROL METABOLIC DISORDER AND THAT MORE PATIENTS WITH SLO DON'T HAVE AUTISM THAN DO SO THAT'S PROBABLY NOT THE BIG ANSWER TO THIS QUESTION. AND THEN FINALLY AS I TALKED ABOUT THE PAT WORKS AND NETWORKS OF QUITE SOBERING IN THEY TURN OUT TO BE THE SAME NEURODEVELOPMENTAL DISORDERS FOR SURE AND MANY PSYCHIATRIC AND NEUROLOGIC ILLNESSES INCLUDING SCHIZOPHRENIA WHERE THE MATT WAY AND THE GENES HAVE BEEN DETERMINED TO BE IN VARIANTS ARE ALMOST IDENTICAL. SO EVERY TIME WE READ A PAPER OR CERTAINLY IF WE'RE HEARING ABOUT IT ON NPR, ASK SIGNIFICANCE ON IMPACT. SEGGANCE IS TYPICALLY NOT AS GREAT AS THE HEADLINES. THE IMPACT SIMILARLY BUT AS SIGN TIPS WE SHOULD BE ABLE TO TAKE THAT HEADLINE AND GET BACK BEHIND IT AND SAY WHAT COULD IT MAN AND HOW MIGHT WE USE IT. SO THE REALITY IS THAT THERE IS SIGNIFICANT PROPORTION OF AUTISM THAT IS RELATED TO ACTUALLY SINGLE GENE DEFECTS OR SIMPLE CHROMOSOMAL ABNORMALITIES. ABOUT 10% IN SOME STUDIES AND 6% OVERALL IS CLOSEST. IF YOU TALK TO THE GENE JOCKEYS THEY'LL TELL YOU THAT THEY THINK THAT THEY'RE GOING TO BE ABLE TO FIND 55 TO 60% OF CASES OF AUTISM WILL HAVE SOME GENETIC COMBINATION OF ABNORMALITIES. STRAIGHIT'S A TINY PIECE OF THAT PIPE AND THERE ARE ONLY A FEW CASE RECORDS. -- WAS ONE OF THE DRUGS THAT CAUSED AN AUTISM SPECTRUM AND I FORGOT THE NAME -- USED IN EARLY PREGNANCY HAS BEEN REPORTED TO RESULT IN AUTISTIC PICTURE AS WELL. AS WITH MOST DISORDERS, THE PATHOGENESIS IS THE COMBINATION OF GENETIC SUSCEPTIBILITY AND ENVIRONMENTAL EXPOSURES. WE HAVE AN ADDITIONAL PIECE IN AWE DISSAL THAAUTISM THAT IS INTERRELATED TO THE STAGE OF NEURO DEVELOPMENT SO THIS IS SOMETHING THAT'S HAPPENING IN THE FIRST TRY MERSE OR THE SECOND. THIRD TRIMESTER WAS THE POSTPARTUM AS MANY OF THE ADVOCACY GROUPS ARE CLAIMING. THE ENVIRONMENTAL TRIGGER IS A SUSCEPTIBLE INDIVIDUAL. WE GO FROM THEIR INDYSFUNCTION AND DAMAGE OF AUTISM. I THINK IT'S A HUGE QUESTION THAT THERE ARE SOME EXCITING POSSIBILITIES THAT IT ACTUALLY JUST AS FUNCTION AS NOT OPEN -- INTRACTABLE IMTREATABLE DAMAGE AND THAT'S COMING OUT BY MARK BEAR AND OTHERS SHOWING TREATMENT EVEN OF ADULT MICE IS SUFFICIENT IN REDUCING A LOT OF OF THE BEHAVIOR ABNORMALITY. IN AUTISM THE GENETICISTS TEND TO THINK ABOUT IT IN THEE DIFFERENT WAYS. ONE IS THAT IT'S GOING TO BE A RARE VARIANCE, THE DENOVO MUTATION AND THE OTHER GETS A COMPLEX COMPLICATED ARRAY OF COMMON VARIANTS THAT HAS JUST MISSORTED IN THIS INDIVIDUAL TO RESULT IN AUTISM. YOU HAVE TO LOOK AT THEM AND THOSE WHO DO GENETICS I'M NOT GOING THERE BECAUSE I DON'T BUT THE STATISTICS ARE QUITE DIFFERENT AND THE POPULATIONS THAT NEED TO BE TESTED ARE QUITE DIFFERENT. AND THE ONE THING THAT NIMH IN COMBINATION WITH OUR SISTER INSTITUTES IS DOING RIGHT IS TO WORK WITH THE PRIVATE FOUNDATIONS TO GET LARGE NUMBERS OF PATIENTS WITH AUTISM SPECTRUM DISORDERS. NOW WE CAN FIGHT ABOUT WHETHER THOSE WHO ARE -- BECAUSE THEY HAD PDD OR ASPERGER'S DISORDER AND WERE DIAGNOSED ON THE BASIS OF PAPER INTERVIEWS HAS BEEN INCLUDED IN THAT SPECTRUM BUT THOSE DATA CAN BE SEPARATED OUT AS TIME GOES ON TO THE NATIONAL DATA BASE OF AUTISM RESEARCH. ENVIRONMENTAL PATHOGENS BECAUSE OF THE FACT THAT YOU HAVE TO BE ABLE TO KNOW WHEN THE MEEK PERIOD OF VULNERABILITY WILL BE. WE CHASED FOR A LONG TIME THIS NOTION THAT IT WAS MERCURY OR VACCINES AND THAT THAT WAS THE CONTRIBUTING CAUSE TO AUTISM PARTICULARLY REGRESSIVE AUTISM. SOME VERY NOTORIOUS INDIVIDUALS HAVE SORT OF FOCUSED ON THAT. I ACTUALLY WAS PRETTY HE CAN SPITE AS I WAS GETTING READY FOR THIS TALK TO REAL EYE THERE HADN'T BEEN A MERCURY HEAD LINE IN THE PAST YEAR. SO MAYBE IT'S FINALLY DYING DOWN AND WE'RE GOING TO GET AWAY FROM IT. THERE WERE A COUPLE VACCINE HEADLINES SO IT'S NOT TOTALLY GONE AND CERTAINLY IF YOU HAVE YOUNG CHILDREN YOURSELF THAT ARE STILL GETTING VACCINATED OR KNOW FOLKS THAT ARE WHEN WE'RE SIGNING THOSE CONSENTS THAT LIST ONLY ALL THE BAD THING THAT COULD HAPPEN AND NOTHING ABOUT WHY YOU MIGHT WANT TO GIVE YOUR CHILD THAT SPRAKS SEEN, THE BEHAVIORAL ABNORMALITIES IS STILL ON THERE. JENNY MCCARTHY AND HER FRIENDS HAVE JUST HAD A TREMENDOUS IMPACT AND IF YOU WANT A GOOD SCIENTIFIC NOVEL TO READ BUT IT'S TRUE AND I HAVE TO DESCRIEIVET AS DESCRIBE AS A NOVEL IT'S CALLED -- IT'S A GOOD READ ABOUT WHAT HAPPENED TO MAKE US ALL THINK THAT MERCURY WAS POISONING OUR KIDS. DR. INSELL TALKS ABOUT THIS SLIDE BECAUSE IT'S ONE OF HIS PET PEEVES ABOUT THE TIME MONEY AND ENERGY THAT HAS BEEN WASTED ON DETERMINING WHETHER OR NOT MERCURY PLAYED A ROLE ON AUTISM AND IT WAS BASED ON FALSE ASSUMPTIONS THAT WERE THEN BY SOME DATA. ALL OF THEM FAILED TO SHOW RELATIONSHIP AND THE ADVOCATES REMAIN UNCONVINCED AGAIN PROBABLY BECAUSE OF THE WAY SCIENTISTS TALK VERSUS THE WAY -- TALK. ONE IS ENOUGH AND YOU GO WITH THAT. SCIENTISTS WE NEVER HAD 100% IF WE GET 99.999 WE FEEL LIKE WE'VE DONE REALLY REALLY WELL BUT WE'RE NOT GOING TO SAY OH IT'S A CASE. SO THIS HAS BEEN A HUGE AND CONTINUING ISSUE. THE REASON IT CONTINUES TO BE A PROBLEM IS THAT ONCE -- WAS REMOVED FROM THE VACCINE, MERCURY WAS DEFINITIVELY PROVEN NOT TO PLAY A ROLE. SOME OTHER FACTORS WITHIN THE VACCINES CREPT IN AND I THINK IT GETS BACK TO THAT WHOLE QUESTION OF SOMETHING HAD TO HAPPEN TO MAKE THIS DISEASE IN MY CHILD. THE MAIN TIME YOU'RE GETTING YOUR VACCINES IS BETWEEN 12 MONTHS AND 18 MONTHS OF AGE. THE PEAK AGE AT FIRST MANIFESTATION OF SYMPTOMS OF AUTISM IS EXACTLY IN THAT SAME TIME FRAME. AND I WOULD SLAISHT CERTAINLY CONCLUDE IF MY CHILD HAD A FEFE A FEVER AND THAT DAYS OF DAY WAS MORE LETHARGIC. THE PROBLEM IS HOW DO WE GET BEYOND THAT AND SORT IT OUT. WE GO FROM THE CLINICAL PICTURE BACK TO THAT ENVIRONMENTAL TRIGGER AND HERE WE JUST NEED TO BE SOBER AND THE OBESE MOMS IS COMING FROM OUR FAVORITE GROUP IN CALIFORNIA WHO CONTINUE TO MIND THIS DATA SOCIETY ENVIRONMENTAL POTENTIAL -- SET OF ENVIRONMENTAL POTENTIAL FACTORS AND THIS TIME CONCLUDED IT WAS MATERNAL OBESITY. THE FACTORS THAT YOU THINK ABOUT THAT MIGHT BE CONTRIBUTING TO THAT ARE NOT ABLE TO BE DETERMINED. SO YOU'RE LEFT WITH AUTISM OF AN N OF ONE DISORDER. EVERY CHILD UNIQUE, EVERY CHILD DIFFERENT. JUST A HUGE BEHAVIORAL SPECTRUM AND WE JUST KIND OF HAVE TO ACCEPT IT AS THAT FUNNEL THAT DR. THERM PRESENTED US WITH. HOW ARE YOU GOING TO GET HANDLE ON THAT HOW ARE YOU GOING TO GRASP IT. I THINK THE ANSWER COMES FROM PHENOTYPING AND THIS IS WHAT SHE WAS ALLUDING TO IN TERMS WITH OUR PANDAS. THE REASON WE'RE DOING THE AUTISM RESEARCH IN THE INTRAMURAL PROGRAM AT NIH IS BECAUSE OF THE SUCCESS WE HAD WITH OBSESSIVE COMPULSIVE DISORDER. WE HAD THE LUXURY OF IN-DEPTH PHENOTYPING OF HUNDREDS OF CHILDREN AND ADOLESCENCE WITH OCD AND IN THAT FOUND A GROUP OF CHILDREN WHO HAD AN UNUSUAL CLINICAL COURSE. THEY HAD AN ABRUPT ONSET OF THEIR SYMPTOMS AND THANKS TO THE OBSERVATIONS IN ONE MOM AND 9 FACT WE WERE LOOKING FOR MEDICAL MODELS AND WE'RE CURRENTLY STUDYING -- WHICH IS THE NEUROLOGIC MANIFESTATION OF RHEUMATIC FEVER, WE WERE ABLE TO MAKE THAT CONNECTION THAT THAT ABRUPT ONSET HAPPENED AFTER STREP INFECTION. THAT'S WHAT WE'RE DOING IN OUR SUBTYPING STUDIES AND IN OUR PHENOTYPING EFFORTS WITHIN OUR BRANCH IS TO LOOK AT ENOUGH YOUNG CHILDREN EARLY IN THE COURSE OF THEIR AUTISTIC SYMPTOM, FOLLOW THEM FORWARD, TAKE VERY CAREFUL FAMILY HISTORY, WORK WITH COLLABORATORS TO DO IN DEPTH BRAIN IMAGING, NEURO IMAGING, EEG WITH STUDIES. THE LIST IS ACTUALLY QUITE INTENSE. THE BEHAVIORAL MEMBER MEASURES ALONE TAKE US A DAY WITH THE PARENT INTERVIEWS AND TESTING WITH THE CHILD. NOT AT THE SAME TIME YOU WANT TO EXASPIRATE THE POOR CHILD BUT PHENOTYPING AND DETAILED MEDICAL CLINICAL AND COLLECTION OF BY I DON'T MEDICAL SAMPLES WE SHARE WITH COLLABORATORS ACROSS THE COUNTRY FOR THEM TO LOOK AT THINGS. I'LL SHARE A COUPLE RESULTS. ONE OF THE THINGS WE HAVE ACTUALLY DISCOVERED IS THAT IT'S IMPORTANT TO SHARE NEGATIVE IN THIS FIELD. SO MANY PEOPLE JUST LIKE MERCURY, THEY'RE CHASING FALSE LEADS. WE WERE CHASING THIS COMPLEX VERSUS SIMPLE FORMS OF AUTISM AND THERE WAS A GREAT DEAL OF EXCITEMENT THAT YOU COULD DO A CAREFUL DISMORPHOLOGY EXAM IF THOSE WHO NEEDED GENETIC TESTING AND THOSE WHO DIDN'T. THOSE THAT NEEDED THE GENETIC TESTING DONE MIGHT HAVE VERY FINE DISMORPHIC FEATURES. MAKE THEY HAD SINGLE CREASE IN THEIR PALM OR THEIR FINGER LENGTHS IS A LITTLE BIT DIFFERENT. IT TURNS OUT THAT ISN'T TRUE. THE CHILDREN WITH AUTISM ARE MORE BEAUTIFUL BECAUSE OF THE SYMMETRY OF THEIR FACE AS A GROUP THAN THE TYPICALLY DEVELOPING CHILDREN OF THE SAME AGE. NO UNIQUE DIS MORPHOLOGY. WE DIDN'T HAVE EVIDENCE OF MITOCHONDRIAL DISORDERS. IF YOU FOLLOW THE NEWSPAPER TRAIL ON AUTISM, HANNAH PO LIEN IN THE PACKS LIEN ISSUE CAME BECAUSE OF THE CONCERN SHE HAD A MITOCHONDRIAL DISORDER AND THE VACCINE TRIGGERED OFF HER DEVELOPMENTAL TRANSGRESSION. AND ALSO THE REGRESSIVE AUTISM IS NOT AS CLEAR CUT AS THIS CHILD HAS A REGRESSIVE PATTERN, THEREFORE WE CAN LOOK FOR ENVIRONMENTAL TRIGGERROR WE CAN LOOK AT THE DEVELOPMENT AND SEE WHY IT WOULD FOLLOW UP. THERE IS FOUR GROUPS AS A CONTINUUM BETWEEN LOSS OF SKILLS AND FAILURE TO DEVELOP THOSE SKILLS TO BEGIN WITH. INTERESTING POSITIVES GET INTO THIS NEXT WEEK SO COME AND LISTEN HARD ABOUT CELIAC DISEASE AND FIND OUT MAYBE YOU DON'T WANT TO STOP EATING WHEAT IF YOU DON'T HAVE TO STOP EATING WHEAT. IN FACT THERE WAS A STUDY OUT OF PAIN ISPAIN ON ADULT VOLUNTEERS WHEN THEY WENT ON A GLUTEN FREE DIET THEY DEVELOPED THE KIND OF GASTRO INTES INTESTINAL INFLAMMATORY DIETS. I MIGHT COME NEXT WEAK AND FIND OUT WHAT THEY HAVE TO TELL US BECAUSE IT'S ONE OF THOSE CAUSE AND EFFECT THINGS. IF YOU DON'T STUDY SOMEBODY AHEAD OF HAVING DONE THIS YOU'RE NOT SURE IT'S GOING TO BE USEFUL. TO KNOW WHETHER OR NOT IT'S GOING TO BE HELP F. IT'S NO EVIDENCE THAT THE GLUTEN FORTY THREE CASING IS USING THERE ARE A LOT OF ANT TOTAL REPORTS OF HOW HELPFUL IT HAS BEEN AND IT MAY TURN OUT IT'S THE SAME AS THE FEINGOLD DIET FAT THE FAMILIES ABLE TO ADHERE TO THE FEINGOLD DIET RELIGIOUSLY WERE THOSE ABLE TO PROVIDE THE BEHAVIORAL SCAFFOLD AND IT WAS ACTUALLY THAT THAT WAS HELPING THE CHILDREN. WE'RE NOT DOING THOSE STUDIES BUT THEY ARE BEING DONE IN A NUMBER OF CENTERS ACROSS THE COUNTRY TO DETERMINE WHETHER OR NOT GLUTEN FREE CASING IS HELPFUL BUT IN THE MEANTIME I CAN TELL YOU IT IS PART OF A NUTRITIONAL DEFICIT IN THESE KIDS THAT IN A NUMBER OF CHILDREN NOW HAVE BEEN REPORTED TO DEVELOP RICKETS, GOOD OLD FASHION RICKETS AS A RESULT OF THE CALCIUM AND VITAMIN D DEFICIENCIES FROM BEING ON A CASE IAN GLUTEN FREE DIET. IF IT'S NOT BEING HELPFUL TO THE CHILD IT NEEDS TO BE STOPPED. WE ARE FOLLOWING IT VERY AGGRESSIVE THERE TO DETERMINE IF THE ABNORMALITIES AND SLEEK ARCHITECTURE WE SAW IN THE CHILDREN WITH AUTISM MAY HAVE A GREATER MEANING IN AN ABILITY TO TREAT. THIS IS A CORE SYMPTOM MORE IMPORTANTLY TO GIVE US A BETTER HANDLE ON WHAT'S GOING ON IN THE NEUROCHEMISTRY IN THE BRAINS OF CHILDREN WITH AUTISM. WE HAD 60 CHILDREN WITH AUTISM, 15 TYPICALS AND 13DD CHILDREN UNDERWENT POLY -- AND OVERSLIGHT SLEEP STUDY IN THE CHILDREN WITH AUTISM THEIR TOTAL SLEEP TIME WAS REDUCED AND EVEN MORE REDUCED WAS THE PERCENTAGE OF TIME SPENT. RAPID EYE MOVEMENT SLEEP HAS BEEN TAUGHT TO PLAY A KEY ROLE IN MEMORY CONSOLIDATION WHICH IS CRUCIAL FOR LEARNING AND DEVELOPMENT AND IT ISN'T HARD TO BEGIN TO SPECULATE THAT IF YOU HAD A CORE DEFICIT IN YOUR ABILITY TO CONSOLIDATE MEMORIES THAT YOU MIGHT START EVERY DAY OVER A FRESH AND THAT WOULD BE RELATIVELY HARD THING TO DO IF YOU'RE ONLY 18 MONTHS AND TRYING TO LEARN THE COMPLEXITIES OF GIVE AND TAKE. IN THE AUTISTIC GROUP THOSEE THOSE REM -- WHICH IS THAT IT HAS BEEN REPORTED TO INCREASE REM SLEEP IN ADULTS WITH ALZHEIMER'S DISEASE. IT WAS ABLE TO INCREASE THE RECOMMEND SLEEP IN THIS GROUP OF PATIENTS AS WELL. THIS IS OCCURRED FROM JUST TWO OF THE PATIENTS SHOWING THAT AT ABOUT ONE AND-A-HALF TO TWO MILLIGRAMS PER DAY OF -- THAT THE REM SLEEP CAME UP INTO THE NORMAL RANGE. WE HAVE JUST SUBMITTED TO THE IRB A DOUBLE BLIND PLACEBO CONTROL TRIAL TO DETERMINE IF IT'S GOING TO HAVE ANY EFFECTS ON THE BEHAVIOR. WE JUST DID IT IN THE SMALL GROUP OF KIDS TO SEE IF WE GET A SPECTRUM SLEEP NOW THE QUESTION IS IDENTIFY GROUP OF AUTISTIC CHILDREN WITH REM DEFICITS AND THEN FIND OUT IF THIS MEDICATION WILL MAKE ANY DIFFERENCE IN THE TRAJECTORY OF THE DEVELOPMENT OVER TIME. WHAT I WANTED TO SAY IS THE SPA MUELLEINTRAMURAL POEM IS PART OF A LARGE RESEARCH NETWORK THAT IS SUPPORTED NOT JUST BY THE NIH BUT BY THE SIMMONS FOUNDATION IN AUTISM SPEAK AND THAT WE'VE HAD TO WORK TO FIND A ROLE FOR OURSELVES BUT AS WITH MANY DISORDERS WITHIN THE IRP, I THINK THE THING THAT WE CAN DO THAT OTHER FOLKS CAN'T IS THIS IN-DEPTH PHENOTYPING. YOU CAN IMAGINE YOU'RE NOT GOING TO WRITE A GRANT WHEREAS THE SPECIFIC AIM IS GO FISHING AND SEE IF I CATCH ANYTHING. THAT PROBABLY WOULD NOT BE VERY FAVORABLY INCLINED TOWARDS THAT BUT SIMILARLY ONCE WE FIND SOMETHING AND THEN IT'S NOT IN OUR PARTICULAR AREA OF EXPERTISE, IT'S IMPORTANT FOR US TO GET THAT INFORMATION TO THE OUTSIDE COLLABORATORS AND MOVE IT AHEAD. SO IT'S LED TO OUR MISSION STATEMENT FOR A BRANCH AT LEAST FOR THE INTRAMURAL AUTISM RESEARCH PROGRAM STILL AIMING FOR THE CAUSES CURES AND PREVENTIVE STAGES FOR AUTISM BUT TO DO MEANINGFUL UNTIL THEN RESEARCH. THANK YOU. [APPLAUSE] >> DO YOU HAVE QUESTIONS? >> [INDISCERNIBLE] >> [INDISCERNIBLE] HAVE BEEN REPORTED TO MEET AUTISM SPEAK TRUMP CRITERI -- SPECTRUM CRITERIA [INDISCERNIBLE] WILL THAT CHANGE IN DSM5. WE ACTUALLY ARE ABLE TO LOOK AT THAT IN SOME OF THE WORK GROUPS, IN THE WORK GROUP MEMBERS OWN CLINICS FOR EXAMPLE WALTER KAUFMANN HAS A BIG PROJECT X POPULATION [INDISCERNIBLE] >> [INDISCERNIBLE] >> AREAS WHERE THERE'S A BEAUTIFUL ANIMAL MODEL -- EXTENDED TO AUTISM, DR. THERM AND I ARE WORKING WITH THE ANIMAL RESEARCHERS SUCH AS JACKIE CRAWLEY TO MAKE SURE THAT TEXT THEY'RE USING ARE ACTUALLY APPLICABLE. ONE OF THE BIGGEST QUESTIONS IS ARE THE ANIMAL MODELS NOW MODELS FOR AUTISM SPECTRUM DISORDER GIVEN THE COMPLEXITY OF THE SOCIAL INTERACTIONS. THEY D>> THEY DO NOT HAVE AN ANIMAL MODEL FOR AUTISM AND THEY NEVER WILL. NOT BEING CRITICAL BUT WHAT THEY ARE USING USUALLY USE SMELL AS THEIR WAY OF INTERACTING A LITTLE BIT DIFFERENT FROM WHAT YOU SAW IN THOSE VIDEOS. THE OTHER THING IS THEY WERE ONLY LOOKING AT THE SOCIAL PIECE BY YOU KNOW HAVING NEW NOVELS MIGHT COME IN AND GO IN OTHER CAGES AS THEY HAVE NOT LOOKED AT THE COMMUNICATION ASPECT SO MUCH. SO AS WE KNOW, RODENTS COMMUNICATE A LITTLE BIT DIFFERENTLY BUT STARTING TO DIFFERENTIATE BETWEEN VOCALIZATIONS AND FIGURE OUT WHAT IS GRIEVING VERSUS A REQUEST AND THING LIKE THAT IN MICE. A LITTLE BIT TRICKY. [INDISCERNIBLE] >> >> THE QUESTION WAS ABOUT TREATMENT AND I THINK IT'S A SUE PUSH QUESTION APPLIED BEHAVIOR AND ANALYSIS AND BEHAVIORAL INTERVENTIONS HAVE BEEN, ARE THE MAIN STAY FOR AUTISM TREATMENTS. I THINK WE ARE NEED TO BE SOMEWHAT CAUTIOUS, IS THAT FAIR. ACTUALLY QUITE CAUTIOUS ABOUT OUR APPLICATION OF THOSE STRATEGIES AND THE PROBLEM IS THAT NOW PROBABLY UNETHICAL TO DO THE APPROPRIATE CONTROL TRIAL. BECAUSE OF THE POPULARIZATION OF THESE STRATEGIES AND THE FEAR THAT IF YOU DON'T DO EARLY INTERVENTION YOU WILL NOT BE HAVING THE EFFECT THAT YOU NEED TO FOR THESE CHILDREN BUT THE REALITY IS THAT THE BEHAVIORAL TREATMENT DATA DEPEND ALMOST EXCLUSIVELY ON THREE TRIALS. TWO OF WHICH WERE TWO SMALL TO DETERMINE EFFICACY AND THE THIRD ONE WHICH CHANGED OUTCOME MEASURES AND FOCUS THE MUCH MORE ON ABA EFFECTIVENESS FOR WHAT IT WAS DEVELOPED FOR WHICH IS INTELLECTUAL DISABILITY AND MENTAL RETARDATION. SO THE QUESTION ABOUT TREATMENTS IS REALLY GOING TO HAVE TO DEPEND ON US BEING ABLE TO DEVELOP OUTCOME MEASURES THAT CAN LET US LOOK AT CHANGE OVER TIME IN DEVELOPING KIDS. >> THIS IS A FOLLOW UP TO THE TREATMENT QUESTION AND I WAS ONE RING WHEN YOU WERE TALKING -- WONDERING WHEN YOU WERE TALKING ABOUT DESPERATE PARENTS WHO HAVE CHILDREN WHO NEED HELP IN SCHOOLS IF IN FACT THE FACTS YOU ARE SEEING ARE NON-AUTISTIC KIDS BENEFITING FROM THESE INTENSE INTERVENTIONS AS OPPOSED TO THE AUTISTIC KIDS WHO ARE BENEFITING. IF YOU GO HE TO MEASURE YOUR OUTCOMES YOU GOT TO KNOW WHICH GROUP YOU'RE MEASURING. >> YES. WELL WE TALK ABOUT HERE ARE MODERATORS AND MEDIATORS OF THESE TREATMENTS. SO THE ONE THING WE KNOW FROM THE ABA STUDIES WAS THAT THEY DID LOOK AT WHO GOT THE MOST BENEFIT AND IT WAS THE KIDS WHO HAD THE HIGHEST IQ TO BEGIN WITH. >> BUT THIS IS A REAL SORT OF TICKING IF YOU FOUND A DRUG THAT WORKS ON AUTISTIC KIDS AND YOU'RE FEEDING IT TO ALL THESE OTHER KIDS. >> I THINK AT THAT POINT I HOPE WE WOULD BE ABLE TO SEPARATE THEM. I WOULD FIRST LIKE TO SEE, HAVE A BETTER HANDLE IN SOME OF OUR TEAMS EFFECTIVE WORKING VERY HARD ON THIS. THAT THE OUTCOME MEASURES NEED TO BE MORE APPROXIMATE TO THE DECISIONS OF CONCERN. SO THE ABILITY TO MEASURE CHANGE IN A DEVELOPING CHILD AND DETERMINE WHETHER IT'S THE TREATMENT EFFECT REQUIRES YOU TO HAVE CHANGED THAT TRAJECTORY OF CHANGED THE FLOW OF DEVELOPMENT. AND THOSE CURVES ARE NOT YET WORKED OUT WITH ANCHOR POINTS AT EACH OF THE DEVELOPMENTAL LEVELS. BUT WE ARE TRYING. WE ARE TALKING ABOUT HUGE MOVING TARGETS HERE OF VERY HUGE VARIABILITY AND AGE IN DEVELOPMENTAL LEVEL AND ALSO WHAT THESE CHILDREN ARE DOING. UNETHICAL IS TO BE HOLDING EVERYTHING ELSE CONSTANT WHICH OF COURSE THE PARENTS WHO ARE GOING TO BE WANTING TO SEE HOW THESE TREATMENTS ARE ALSO GOING TO BE DOING TEN OTHER THINGS TO BE HELPING THEMSELVES AT THE SAME TIME. NOT EASY. >> [INDISCERNIBLE] >> YES OUR DSM5 COMMITTEE IS ALMOST EXCLUSIVELY REACHED AUTISM AND NEURODEVELOPMENTAL DISORDER RESEARCHERS WHO WE ARE EXACTLY DOING THAT. SO AS WE WROTE THE CRITERIA AND SPECIFIED THOSE THINGS, ONE OF THE REASON TO COMBINE SOCIAL AND COMMUNICATION INTO ONE IS NOT JUST SO YOU WOULDN'T BE DOUBLE COUNTING LACK OF NON-VERBAL COMMUNICATION IN BOTH OF THOSE BUT MORE IMPORTANTLY SO YOU COULD BEGIN TO REALLY PARSE OUT WHICH CHILDREN HAVE WHICH TYPES OF DEFICITS AND REQUIREMENTS. >> EVEN DA EPIDEMIOLOGY THEIR RELATIONSHIP BETWEEN COUNTRIES THAT HAVE A SINGLE PAIR OF HEALTH INSURANCES AND DON'T THAT DON'T. >> THERE'S AN INTERNATIONAL EPIDEMIOLOGY NETWORK AND THERE'S A STUDY WE'RE GOING TO BE DOING ON OUR BRANCH MEETING TOMORROW FROM KOREA, WHAT THEIR RATES ARE. THE CULTURAL DIFFERENCES IN SOCIAL COMMUNICATION ARE SO PROFOUND IT'S HARD TO MAKE CORRECTIONS FOR THAT. BUT THE OVERALL RATE HAS STAYED FAIRLY CONSTANT ACROSS THE WORLD IN DEVELOPED AND UNDEVELOPED COUNTRIES WITH THAT ONE PERSON. >> IS THERE ANY DISTINCT PATHOLOGY AND IN THE BRAIN OR OUTSIDE OF THE BRAIN. >> NO. >> FAIR ENOUGH. >> NEGATIVE TO SAY. THE SIMPLE ANSWER IS NO. I WOULD KILL FOR IT. AND AGAIN COMING FROM OCD WHERE WE JUST LUCKED INTO THE ORBITAL CORTICO IT'S LIKE THAT'S SO EASY. NO, THERE ARE MANY DIFFERENT REPORTS AND CONFLICTING DATA SETS. DR. -- IS HERE AND HE CAN TELL YOU OUR EXPERIENCE WITH BTI WHERE YOU CAN MAKE A BIG DEAL ABOUT THE FACT YOU HAVE A SIGNIFICANCE DIFFERENCE BETWEEN TYPICALS AND AUTISTIC CHILDREN. ON THE OTHER HAND IT'S 1% DIFFERENCE IF SOMEBODY WOULD HAVE MISSED THE BUS. >> I HAVE A QUESTION IN FULL DISCLOSURE I'M LAURA CARTER THE EDITOR FOR THE NIH CATALYST AND WE'RE DOING A BIG STORY ON AUTISM AND YOU'VE VERY KINDLY REVIEWED PARTS OF THE STORY. WHAT HAS THE INTRAMURAL PROGRAM DONE TO REALLY CONTRIBUTE TO DISCOVERIES IN AUTISM THAT YOU MENTIONED WE CAN DO SOME OF THE PHENOTYPING. DID WE MAKE THE MERCURY DISCOVERY THAT IT'S NOT CONNECTED OR WHAT CAN WE SAY AS AN INTRAMURAL PROGRAM ARE OUR -- >> WE ARE BASED IN THIS FIELD. DR. THERM AND I WERE EXTRAMURAL UNTIL 2006 AND AT THAT POINT THE INTRAMURAL AUTISM RESEARCH PROGRAM WAS CREATED WITH US AND WE WORKED VERY VERY VERY HARD TO ACTUALLY CREATE A REAL AUTISM RESEARCH PROGRAM WITHIN THE INTRAMURAL COMMUNITY. OUR FINDINGS TO DATED ARE QUITE LIMITED TO BE PERFECTLY HONEST. THE NIH INTRAMURAL PROGRAM CONTRIBUTION TO BE THIS HAS BEEN TWO-FOLD. ONE, WE HELPED WITH THE INITIAL DEVELOPMENT OF THE NATIONAL DATA BASE FOR AUTISM RESEARCH WHICH IS A VEHICLE THAT WILL ALLOW IN THEORY THE GRADUATE STUDENT IN BANGLADESH TO TAKE ALL THE DATA FROM ALL OF THE INDIVIDUALS WITH AUTISM STUDIED WITH ANY NIH GRANT AS WELL AS THE INTRAMURAL PROGRAM AND THE SECOND THING IS THE FINDING OF THE SLEEP. IT'S ACTUALLY PRETTY PROFOUND THAT A TRUE BIOLOGIC ABNORMALITY IN AUTISM REPLICATED CLEARLY DISTINCT FROM TYPICALLY DEVELOPING CHILDREN HAS BEEN FOUND AND THAT'S WHAT WE'RE CHOOSING TO FOCUS ON. >> [INDISCERNIBLE] >> I'M SORRY WHAT. >> NOT HEPATITIS. >> THE NIH TRANSFUSION DEPARTMENT FINDING WHAT. >> CAN I JUST ASK YOU A QUICK QUESTION. FOR THE PANDA, DID YOU MAKE THAT DISCOVERY BETWEEN THE STRESS. >> NOT ME PERSONALLY BUT -- >> YOUR LAB. >> OUR GROUP. >> I NEED TO ADD THAT TO THE ARTICLE. >> OKAY. YES WE HAVE ACTUALLY DONE SOMETHING IN THE 25 YEARS. >> OKAY. WELL ON BEHALF OF ALL OF US I WANT TO THANK YOU VERY MUCH.