I'M HARRY BURGESS FROM NICHD AND IT IS MY VERY GREAT PLEASURE TO WELCOME DR. MATTHEW STATE, PROFESSOR OF PSYCHIATRY AND CHAIR OF THE DEPARTMENT OF PSYCHIATRY AT UCSF. SO MATT DID HIS B.A. AND M.D. AT STANFORD UNIVERSITY. HE THEN TRAVELED TO THE OTHER COAST, TO YALE UNIVERSITY, WHERE HE JOINED DAVID WARD'S LAB, STUDYING TOURETTE SYNDROME. THERE HE DESCRIBED AN UNUSUAL CHROMOSOMAL REARRANGEMENT THAT LED TO SOME REALLY INTERESTING UNDERLYING EPIGENETIC SILENCING THAT WAS CAUSAL FOR TOURETTE'S. AT THE END OF HIS PH.D., HE WAS RECRUITED AS ASSISTANT PROFESSOR IN PSYCHIATRY AND CHILD PSYCHIATRY AND GENETICS, AND HE REMAINED AT YALE FOR ANOTHER 12 YEARS, WHERE HE EVENTUALLY ROSE& TO THE RANK OF FULL PROFESSOR. SO THERE HE DID MANY EXPERIMENTS WHICH I THINK HAVE TRANSFORMED FIELDS NOT ONLY OF TOURETTE'S BUT ALSO IN YOU A AUTISM. SO HIS WORK IN TOURETTE'S, IN 2001, HIS IDENTIFICATION OF SLID R K1 DESCRIBED BY SCIENCE MAGAZINE AS BREAK THROUGH OF THE YEAR, BUT I THINK FOR MANY OF US IN THE ROOM TODAY EVEN MORE EXCITECYTING EXCITING WAS THE WORK HE INITIATED ON AUTISM GENETICS, WHICH HAS REALLY TRANSFORMED THE FIELD. WE'VE GONE TO A SITUATION OF HAVING A LIST OF AUTISM GENES VERY CAUSALLY CONNECTED WITH THE DISORDER WITH REALLY SOLID ESTIMATES OF THEIR FALSE DISCOVERY RATE. ABOUT FIVE YEARS AGO, HE MOVED BACK TO CALIFORNIA, WHERE HIS CURRENT POSITION AT U CSF. HE CONTINUES WORK GENE HUNTING IN AUTISM IN TOURETTE'S, AND TWO YEARS AGO, PUBLISHED A PAPER WHICH I THINK IS NOW A TOUCH STONE IN THE FIELD WHICH I THINK MANY OF YOU ARE FAMILIAR WITH. IN FACT MANY OF YOU ARE PROBABLY FAMILIAR WITH THE FAMOUS SUM TRI TABLE 6 WHICH LISTS ALL OF THE AUTISM GENES AND THEIR FALSE DISCOVERY RATE, SO THIS HAS BEEN, I THINK, TRULY TRANSFORMATIVE IN THE FIELD. DR. STATE HAS WON MANY AWARDS. HE LAST YEAR WON THE PRIZE FOR MENTAL HEALTH, HE'S AN ELECTED MEMBER OF THE NATIONAL ACADEMY OF MEDICINE AND HAS SERVED ON COUNTLESS EDITORIAL BOARDS AND ADVISORY BOARDS, INCLUDING UNTIL VERY RECENTLY THE BSC FOR NATIONAL INSTITUTE OF MENTAL HEALTH. SO THANK YOU FOR YOUR SERVICE. I HAVE JUST ONE MORE THING TO SAY. SO I REALLY WANTED TO INVITE DR. STATE FOR OBVIOUSLY BECAUSE THE WORK IS OF FUNDAMENTAL IMPORTANCE OF AUTISM AND TOURETTE'S BUT ALSO FOR AKNOW REASON, AND IT'S THAT WHEN YOU LOOK AT HIS PAPERS, IT'S NOT JUST WORK FROM HIS OWN LAB, BUT THESE ARE BIG COLLABORATIVE ENDEAVORS THAT ARE VERY HARD TO ORGANIZE. MANY OF US THINK OF SCIENCE AS THIS PROCESS WHERE WE'RE A LONELY BLIND PERSON IN THE DARKROOM LOOKING FOR THE BLACK CAT THAT ISN'T THERE, THEY SAY. WHAT'S AMAZING ABOUT DR. STATE'S WORK IS THAT HE'S BEEN ABLE TO BRING TOGETHER MANY RESEARCHERS WHO ARE NOW FORMING A WHOLE TEAM OF BLIND RESEARCHERS LOOKING AROUND THE DARKROOM AND THE INCREDIBLE THING IS THAT THEY'VE FOUND THE BLACK CAT, THEY'VE FOUND MANY BLACK CATS AND I THINK THAT'S WHAT WE'RE GOING TO HEAR ABOUT TODAY. SO THANK YOU. [APPLAUSE] >> THANK YOU. GOOD ON THE MIC, CAN YOU HEAR ME IN THE BACK? GREAT. I'M DELIGHTED TO BE HERE, REALLY THRILLED TO BE ABLE TO TALK TO YOU TODAY ABOUT WHERE THINGS STAND WITH REGARD TO A COUPLE DISORDERS THAT AS YOU'VE HEARD I'VE HL A LONG-STANDING INTEREST IN AUTISM AND TOURETTE DISORDER. I KNOW THIS IS A HETEROGENEOUS CROWD, I'M USED TO HETEROGENEITY, BUT I'M GOING TO START BY TALKING FIRST TO GIVE YOU A SENSE ABOUT SORT OF WHERE WE ARE. A GREAT INTRODUCTION, BUT GIVE YOU SOME OF THE HISTORICAL PERSPECTIVE AROUND MOVING FROM ESSENTIALLY WANDERING IN THE DARK FOR THE FIRST 15 YEARS OF MY CAREER TO NOW REACHING AN ERA OF RELIABLE AND REPRODUCIBLE GENE DISCOVERY FOR NEURODEVELOPMENTAL DISORDERS, AND THEN THE SECOND HALF OF THE TALK, I WANT TO SORT OF POSE WHAT I THINK IS REALLY THE CENTRAL CHALLENGE NOW FOR THESE CONDITIONS, WHICH IS HOW DO WE MOVE FROM GENE DISCOVERY TO AN UNDERSTANDING NOT JUST OF THE BIOLOGY OF THE GENES THAT WE'RE LOOKING AT BUT AS A CLINICIAN, I'M VERY FOCUSED ON UNDERSTANDING PATHOPHYSIOLOGY AND REALLY THINKING ABOUT WHAT THE DIFFERENCE MAY BE BETWEEN ELABORATING BIOLOGY BROADLY AND UNDERSTANDING THE PATHOPHYSIOLOGY OF THESE CONDITIONS. THE WORK I'M GOING TO DESCRIBE FOR YOU TODAY HAS BEEN DONE BY A WHOLE PHALANX OF YOUNG PEOPLE THAT ARE TWICE AS SMART AS I AM. I'M SHOWING THE SORT OF CORE GROUP AT THE END, SO OBVIOUSLY I'LL GIVE SOME ACKNOWLEDGMENTS BUT SOMETIMES WHEN YOU DON'T HAVE ENOUGH TIME IN THE TALK WITH THAT LAST SLIDE KIND OF DANGLING THERE SO I WANT TO MAKE SURE I'M FOCUSED ON THE YOUNG PEOPLE THAT HAVE REALLY BEEN DRIVING THIS WORK OVER ALMOST A DECADE, SO STEFFAN AND JEREMY, I WAS VERY FORTUNATE TO HAVE THEM BOTH AS GRADUATE STUDENTS AND POSTDOCS IN MY LAB AND NOW I'VE MANAGED TO KEEP THEM AT U CSF, THEY'RE WORKING INDEPENDENTLY, THEY HAVE THEIR OWN GROUPS. WE CONTINUE TO COLLABORATE AROUND THE GENETICS BOTH OF AUTISM WITH STEFFAN AND TURRETTE'S SYNDROME WITH JEREMY AND THEN THREE POSTDOCS THAT WILL HAVE LED THE WORK THAT I'M GOING TO SHOW YOU TODAY. SO AGAIN THIS IS A HETEROGENEOUS AUDIENCE AND I'M GOING TO MOVE FROM -- I FIGURED IT WOULD BE WORTHWHILE TO GIVE YOU A BIT ABOUT THE PHENOMENA WE'RE INTERESTED IN AND THE GENETICS OF WHERE WE GO FROM HERE. SO I'M GOING TO SHOW YOU TWO VIDEOS, DON'T WORRY ABOUT THE SOUND ON THIS, IN FACT, I USE THIS VIDEO BECAUSE YOU DON'T NEED TO HEAR ANYTHING TO GET A SENSE OF WHAT THE KIND OF CLINICAL PRESENTATION: THIS IS A 12-YEAR-OLD BOY, FATHER ON THE RIGHT, EXAMINER ON THE LEFT. THIS IS A CHILD WITH CLASSIC AUTISM, WHICH IS REALLY DEFINED BY A FUNDAMENTAL IMPAIRMENT IN RECIPROCAL SOCIAL COMMUNICATION ALONG WITH REPETITIVE BEHAVIORS AND RESTRICTED INTERESTS. AGAIN, WITHOUT -- HE HAS ACTUALLY VERY LIMITED LANGUAGE WHICH IS ALSO OFTEN A PART OF CLASSIC AUTISM, CAN YOU GET A SENSE WITHOUT HEARING ANYTHING ABOUT THE DERANGEMENT IN HIS SOCIAL RELATIONSHIPS AND YOU CAN SEE SOME STEREO TYPIC BEHAVIOR, HAND FLAPPING, CLASSIC FOR ASD. NOW I WANT TO SHOW YOU ANOTHER YOUNG MAN WITH ASD. CAN YOU HEAR THIS? >> NO. >> OKAY. >> I NEVER REALLY SEEMED TO THINK WHAT OTHER PEOPLE ARE THINKING. IT NEVER DAWNED ON ME TO THINK ABOUT THAT. IT NEVER OCCURRED TO ME THAT OTHER PEOPLE WERE PROBABLY THINKING SOMETHING DIFFERENT, AND I STILL HAVE THAT PROBLEM. I STILL DON'T REALLY THINK EXACTLY WHAT OTHER PEOPLE ARE THINKING. I STILL FIND IT DIFFICULT TO THINK WHAT ARE THEY THINKING ABOT? >> SO ONE OF THE THINGS THAT HE'S TALKING ABOUT THERE IS SOMETHING WE CALL THEORY OF MIND THAT HE'S VERY EXPLICIT ABOUT THE FACT THAT HE REALLY DOESN'T UNDERSTAND WHAT OTHER PEOPLE MIGHT BE THINKING AND BY EXTENSION, HE DOESN'T UNDERSTAND WHAT THEY'RE FEELING AND IT MAKES IT EXTREMELY DIFFICULT FOR HIM TO INTERACT. NOW AT THIS POINT HE'S 19 YEARS OLD, AND WENT THROUGH WITHOUT HAVING ANY FRIENDS, COULD NEVER REALLY FIGURE OUT WHY, AND THE NEXT LITTLE BLOCK, HE'S GOING TO TALK ABOUT THE FACT THAT HE HAS A REAL PROBLEM IF PEOPLE TRY TO JOKE WITH HIM, HE CAN'T UNDERSTAND THE JOKE, HE DOESN'T KNOW WHEN PEOPLE ARE JOKING, AND SOCIALLY, AND YOU CAN IMAGINE THAT IF YOU CAN'T UNDERSTAND WHAT SOMEONE ELSE IS THINKING, THEN THE SETUP FOR A JOKE COULD BE, YOU KNOW, COMPLETELY IMPENETRABLE. ONE OF THE THINGS THAT I WANTED TO DEMONSTRATE HERE IS THAT BOTH OF THESE CHILDREN, WHILE YOU WOULD THICK OF THEM THINK OF THEM AS BEING COMPLETELY DIFFERENT, BOTH YOU WOULD AGREE HAVE IMPAIRMENTS IN SOCIAL COMMUNICATION. WE DEFINE BOTH OF THEM AS HAVING AN AUTISM SPECTRUM DISORDER. SO YOU CAN SEE HOW BROAD THE DIAGNOSTIC ENTITY IS, AND IN FACT, I THINK WHAT'S REMARKABLE IS DESPITE HOW BROAD THAT IS, WE CAN TAKE PEOPLE FROM ACROSS THIS ENTIRE SPECTRUM, PUT THEM ALL TOGETHER, DO GENE DISCOVERY AND IDENTIFY GENES THAT ARE RELIABLY AND REPRODUCIBLY ASSOCIATED WITH A PHENOTYPE, AGAIN BROADLY. WE SEE NO SPECIFICITY WHEN WE IDENTIFY GENES FROM ONE END OF THE SPECTRUM OR ANOTHER. WE CAN FIND A SINGLE GENE THAT WILL LEAD TO THE PHENOTYPE ON THE LEFT, THE PHENOTYPE ON THE RIGHT, AND REMARKABLY, WE CAN SEE EVEN TWINS, MONO ZYGOTIC TWINS WHO WILL CROSS THE SPECTRUM. NOW I WANT TO SHOW YOU TOURETTE'S SYNDROME. HERE PEOPLE ARE OFTEN LESS KIND OF FAMILIAR, AUTISM IS ALL IN THE NEWS, TOURETTE IS CHRONIC, VOCAL AND MOTOR TICKS, ONSET IS IN CHILDHOOD. THIS IS A VERY SEVERELY AFFECTED YOUNG MAN. YOU CAN SEE HE HAS -- THESE ARE ALL COMPLEX MOTOR TICKS AND HE'S ALSO SNORTING THROUGH HIS NOSE, WHICH IS ACTUALLY A VERY COMMON FORM OF VOCAL TICK, MUCH MORE COMMON THAN WHAT YOU SEE ON TV, UTTERING OBSCENITIES, PRESENT IN ONLY ABOUT 10% OF PATIENTS. WITH TOURETTE'S, IT DOES HAPPEN, BUT ONLY ABOUT 10%. IT'S MUCH MORE COMMON THAT PEOPLE HAVE THROAT CLEARING, CLEARING THEIR NOSE, THE FIRST PLEN PRESENTATION FOR KIDS IS THEY GO TO AN ALLERGIST. YOU CAN IMAGINE THIS IS ALSO SOCIALLY DISABLING IN ANOTHER WAY, IT CAN BE VERY TOUGH FOR FOLKS TO HAVE THIS, AND INTERACT. BUT A LOT OF THE MORBIDITY ASSOCIATED WITH TOURETTE'S SYNDROME COMES WITH VERY HIGH RATES OF MORBIDITY, THESE ARE PRESENT IN EACH OF THOSE SITUATIONS IN CLINICAL POPULATIONS AT 50% MORE OF THE KIDS THAT WE SEE. SO YOU VERY RARELY SEE A KID WHO'S COMING TO YOU FOR TOURETTE'S SYNDROME SIMPLY BECAUSE THEY HAVE MOTOR OR VOCAL TICS. IT HAPPENS AT TIMES BUT WE SEE VERY HIGH RATES OF THESE OTHER BEHAVIORAL AND PSYCHIATRIC ISSUES. SO THOSE ARE THE TWO PHENOTYPES I'M GOING TO TALK ABOUT. I'M GOING TO SPENT MUCH MORE TIME TALKING ABOUT AUTISM THAN TOURETTE'S. SADLY THAT LAST BULLET IS SAYING TOURETTE'S IS VERY FAR BEHIND AUTISM AND IT REALLY HAS BEEN BECAUSE THERE'S BEEN A TREMENDOUS INVESTMENT IN AUTISM OVER THE LAST DECADE THAT HAS LED TO A LOT OF OUR GENE DISCOVERY AND IT'S ONLY BEEN RECENTLY NOW THAT WE'VE BEEN ABLE TO GENERATE ANYWHERE NEAR THOSE KINDS OF RESOURCES TO BRING MODERN GENOMIC METHODS TO TOURETTE DISORDER. LET ME TALK TO YOU BROADLY ABOUT ABOUT -- I CAN TALK TO YOU ABOUT TOURETTE AND AUTISM WHEN WE THINK ABOUT OTHER NEURODEVELOPMENTAL CONDITIONS, THERE'S STRONG EVIDENCE AS THERE IS FOR MANY PSYCHIATRIC DISORDERS A MARKED GENETIC CONTRIBUTION COMING FROM FAMILY AND TWIN STUDIES. I GOT INTERESTED IN WORKING ON NEURODEVELOPMENTAL DISORDERS BACK IN THE LATE '90S, BEING A CLINICIAN AT UCLA, WHERE I DID MY CLINICAL TRAINING AND AS YOU HEARD, I WENT THEN TO YALE TO DO A PH.D. AND THAT WAS REALLY DRICH BY DRIVEN BY A TREMENDOUS SENSE OF FRUTION TRAITION ON THE WARDS, TAKING CARE OF VERY SICK KIDS WITH NEURODEVELOPMENTAL PROBLEMS AND YET COMPARED TO EVERY OTHER FIELD I KNEW ABOUT FROM MEDICAL SCHOOL OR WOULD ROTATE THROUGH DOING CONSULTATIONS, WE HAD ESSENTIALLY ZERO INSIGHT INTO MECHANISM, MOLECULAR OR PATHOLOGY OF THESE DISORDERS, THEY'RE PROFOUNDLY DEBILITTING AND THAT ABSENCE REALLY SEEMED LIKE A TREMENDOUSLY IMPORTANT BOUNDARY AROUND WHAT WE COULD DO WITH REGARD TO THINKING ABOUT MORE EFFECTIVE TREATMENTS. SO I WENT TO YALE AND STARTED WORKING ON GENETICS, REALLY WITH THE IDEA THAT THERE WERE MANY DIFFERENT APPROACHES TRYING TO UNDERSTAND THESE DISORDERS BUT THE GENE DISCOVERY, AND PARTICULARLY LOOKING FOR GENES THAT HAD VERY LARGE BIOLOGICAL EFFECTS COULD BE AN AVENUE TO BEGIN TO UNDERSTAND SOMETHING IMPORTANT ABOUT THE MOLECULAR CELLULAR AND CIRCUIT LEVEL FUNCTION, SO I WANT TO TALK TO YOU A LITTLE ABOUT SORT OF THAT HYPOTHESIS, AND CLEARLY IT WAS A HYPOTHESIS AT THE TIME, I THINK IT REMAINS WE'VE GOTTEN MORE AND MORE EVIDENCE THAT WE CAN FIND GENES, HOW THOSE ARE GOING TO LEAD TO A DEEPER UNDERSTANDING, I THINK REMAINS A QUESTION I'M GOING TO TALK ABOUT IN THE SECOND HALF OF THE TALK. SO GENE DISCOVERY IS A PARTICULARLY EFFECTIVE AVENUE, FOCUS ON RARE MUTATIONS BECAUSE OF A KNOWN RELATIONSHIP THAT WHEN MUTATIONS ARE RARE IN THE POPULATION, THAT IF THERE IS A CONNECTION WITH THE DISORDER, OFTEN THAT THE EFFECT SIZES ARE LARGER THAN VARIANCE IN THE GENOME THAT ARE COMMON. I'M GOING TO TALK ABOUT THIS A BIT LATER, BUT WE RELY TOOK AN AN EXPLICIT APPROACH SAYING EVEN IF ONLY A TINY FRACTION OF TOURETTE'S SYNDROME AND AUTISM IS CAUSED BY LARGE EFFECT RARE MUTATIONS, WE WANT TO FIND THOSE BECAUSE OUR INTEREST WAS NOT DIAGNOSIS, IT WASN'T EXPLAINING POPULATION RISK, IT WASN'T COURSE PREDICTION, IT WAS TO TRY TO GET TRACTION ON PATHO BIOLOGY. AND WE FIGURED THAT IF YOU COULD FIND SOMETHING THAT HAD BIG EFFECTS IN AN INDIVIDUAL, THAT THE TRANSLATION FROM THAT TO THE BENCH WOULD BE MORE DIRECT THAN FINDING THINGS THAT MIGHT BE MORE COMPLEX AND HAVE SMALLER EFFECTS. THERE'S SOME OTHER THINGS THINKING ABOUT GENETICS AS AN 18 TRI TO AN ENTREE TO PATHOPHYSIOLOGY, THE TRACTION IS POTENTIALLY GIVES YOU ON TEMPORAL DCIAL ANY CROSS-SECTIONAL STUDY YOU DO IN PATIENTS, IT'S EXTREMELY DIFFICULT TO FIGURE OUT WHAT'S CAUSE AND WHAT'S EFFECT. YOU CAN SEE DIFFERENCES IN GENE EXPRESSION, YOU CAN SEE DIFFERENCES IN BRAIN ACTIVATION. YOU SEE DIFFERENCES ALL OVER THE PLACE. THE QUESTION ABOUT WHETHER OR NOT THAT'S DRIVING PATHOLOGY OR THAT'S A RESPONSE TO THE PATHOLOGY IS ALWAYS CENTRAL AND AS I SAID CAN BE VERY DIFFICULT TO TEASE OUT, AND GENETICS, AT LEAST, CONCEPTUALLY GIVES YOU AN APPROACH THAT ALLOWS TO YOU GAIN SOME TRACTION ON THAT BECAUSE THE GENES ARE THERE BEFORE THE BRAIN IS BUILT. SO IF YOU CAN STUDY THEM AND BIOLOGICAL MECHANISMS, AT LEAST THEORETICALLY THAT MIGHT GIVE YOU SOME TRACTION ON AN IMPORTANT QUESTION, IF YOU WANT TO UNDERSTAND PATHOBIOLOGY, THE UNFOLDING OF THE ILLNESS. SECONDLY IS IT CLEARLY GETS YOU TO THE MOLECULAR SCALE. SO COMPLEX BEHAVIORAL PHENOTYPES, IF YOU CAN FIND A GENE AGAIN, EVEN IF IT'S EXTREMELY RARE, YOU'VE JUMPED A WHOLE BUNCH OF LEVELS AND DOWN TO ONE WHICH ACTUALLY IS PROBABLY THE SIMPLEST PART OF THE PROBLEM, RIGHT? SO THE GENOME IS 3 BILLION BASE PAIRS AND THAT'S A PRETTY BIG DATASET, BUT WHEN YOU COMPARE THAT TO THE NUMBER OF NEURONS IN THE CENTRAL NERVOUS SYSTEM OR THE NUMBER OF SYNAPSES IN THE CENTRAL NERVOUS SYSTEM, IT'S ACTUALLY THE REDUCTIONIST APPROACH, IS TO GO FOR 3 BILLION AS OPPOSED TO 100 MILLION OR 100 TRILLION. SO GETTING TO THE MOLECULAR SCALE AND THEN THINKING THAT POTENTIALLY THE HYPOTHESIS WAS THAT YOU COULD CLAW YOUR WAY BACK, MOVING THROUGH INCREASINGLY MORE COMPLEX AND DIFFICULT PROBLEMS BUT IF YOU COULD START WITH THE VARIATION IN THE GENOME, THAT THAT WOULD BE A GOOD THING TO DO, AND THEN AS I SAID, WE WERE FOCUSED EXPLICITLY ON LARGE EFFECTS. SO BY LOOKING AT RARE VARIATION. SO I'M GOING TO TAKE YOU THROUGH KIND OF A QUICK HISTORY NOW OF LEVERAGING THAT STRATEGY TO MAKE PROGRESS ON GENE DISCOVERY AND START BY SHEAING THAT INITIALLY, THERE WERE TWO TYPES OF MUTATIONS THAT WE WERE VERY INTERESTED IN JUST BECAUSE OF HAVING GONE BACK TO DO A PH.D., I TOOK BASIC GENETICS, AND LOOKING FOR THINGS WITH LARGE EFFECT THAT REMAIN IN THE POPULATION, ONE ARE RECESSIVE MUTATIONS, YOU CAN FIND RECESSIVE MUTATIONS THAT HAVE BIG EFFECTS SO WE IMMEDIATELY STARTED LOOKING TO SEE IF WE COULD FIND VERY RARE RECESSIVE FORMS OF AUTISM. BUT THEN INCREASINGLY WE BECAME INCREASINGLY INTERESTED IN NEW OR DE NOVO MUTATIONS AND THERE WERE A COUPLE WREEN REENS FOR THAT. THE FIRST IS THAT CONCEPTUALLY, DE NOVO MUTATION, THESE NEW MUTATION IN THE GERMLINE, SO THEY HAPPEN JUST BEFORE FERTILIZATION, AND THEY'RE PRESENT THEN IN EVERY CELL IN THE OFFSPRING BUT NOT PRESENT IN THE PARENTS. THAT WHEN YOU THINK ABOUT IT, NATURAL SELECTION HAS VERY LITTLE TIME TO ACT ON THOSE KINDS OF MUTATIONS, RIGHT? SO IF THE FETUS SURVIVES AND IS BORN, CAN YOU HAVE VERY SERIOUS NEURODEVELOPMENTAL CONSEQUENCES AND IF YOU HAVE A WAY OF IDENTIFYING THE DE NOVO MUTATION, CAN YOU FIND IT, YOU DON'T HAVE TO RELY ON THE FACT THAT THAT CAN THEN BE PASSED ON FROM GENERATION TO GENERATION. SO DE NOVO MUTATION CONCEPTUALLY GIVES YOU AN AVENUE TO IDENTIFY LARGE EFFECT, SO WE STARTED LOOKING AT CHROMOSOMES FOR DE NOVO CHROMOSOMAL BREAKS AND UNFORTUNATELY THE TECHNOLOGY -- THERE'S A SECOND REALLY IMPORTANT REASON THAT WE STARTED LOOKING AT DE NOVO MUTATIONS AND THAT WAS THAT MIKE WIGLER AND JONATHAN IN ABOUT 2007 SHOWED THAT IF YOU LOOKED AT SUBMICROSCOPIC CHROMOSOMAL CHANGES USING MICRO ARRAYS WHICH WERE RELATIVELY NEW AT THAT TIME, YOU THAT SAW EVEN IN A RELATIVELY SMALL NUMBER OF KIDS THAT THERE WERE A LARGER NUMBER OF DE NOVO CHANGES IN CHROMOSOMAL STRUCTURE IN KIDS WITH AUTISM THAN THOSE THAT DID NOT. IT WAS SEEN IN ONLY 200 KIDS, SUGGESTING THIS WOULD GOING TO BE A BIG EFFECT. WHEN WE THINK ABOUT GENETIC STUDIES NOWADAYS WITH 50,000, 100,000 PEOPLE, SOME EVEN MORE THAN THAT, THAT'S A CONSEQUENCE OF NEEDING THOSE LARGE SAMPLES BECAUSE THE EFFECT SIZES ARE SMALL. IF YOU CAN SEE SOMETHING IN 200 KIDS, IT MEANS THAT THERE'S A BIG EFFECT AS A GROUP OF THOSE KINDS OF MUTATIONS. SO THESE ARE THE KINDS OF FAMILIES THAT YOU COULD IMAGINE WOULD HELP YOU FIND DE NOVO MUTATION, IF THERE WERE NOTHING -- NO PHENOTYPE IN THE PARENTS, IF NO ONE ELSE, NO OTHER FIRST DEGREE RELATIVES WERE AFFECTED AND THERE WAS ONLY A SINGLE AFFECTED CHILD, THIS WOULDN'T GUARANTEE THIS FAMILY WAS SHOWING A DE NOVO MUTATION BUT IT'S THE RIGHT OVERT PATTERN TO SUGGEST THAT YOU MIGHT ENRICH FOR DE NOVO MUTATION AND WE WERE EXTREMELY FORTUNATE THAT THE SIMONS FOUNDATION IN NEW YORK SAW THE RESULTS OF THE WIGLER AND SEBOT WORK IN 2007, ACTUALLY MIKE WAS A CLOSE FRIEND OF JIM SIMONS WHO HAD THIS FOUNDATION, AND HE DECIDED TO GO ALL IN, TO BUILD A COHORT OF PATIENTS THAT WERE EXTREMELY CAREFULLY PHENOTYPED, AND THAT WOULD HELP FIND DE NOVO MUTATIONS.& AT THAT POINT, MOST GENETIC STUDIES WERE EITHER CASE-CONTROL OR FAMILY-BASED STUDIES WITH MULTIPLE AFFECTED INDIVIDUALS. SO THE IDEA THAT SOMEONE WOULD COME IN AND SAY NO, WE'RE NOT GOING TO LOOK FOR CASE CONTROL SAM PAL PEL AND NOT FIND -- WAS PHENOMENALLY IMPORTANT. THANKFULLY JIM SIMONS NOT ONLY MADE A COMMITMENT TO HAVE 3,000 FAMILYS THAT HAD THIS STRUCTURE, BUT THEN ASKED ME, SHOCKINGLY, AS ASSISTANT PROFESSOR, TO LEAD A GROUP OF GENETICISTS WHO BECAME THE SIMONS GENOMICS CONSORTIUM. I THINK ALL ULTIMATELY I THINK WHAT YOU SAID HAD NOTHING TO DO WITH MY SCIENTIFIC PROWESS, HE JUST NEEDED SOMEONE WHO COULD HANDLE THE 12 PEOPLE, SO THEY TURNED TO THE CHILD PSYCHIATRIST. THAT'S WHAT WE DO. SO THEY BUILT THE SAMPLE, NOW I'M GOING TO JUMP OVER ABOUT 10 YEARS WORTH OF WORK, BUT I'M GOING TO TAKE YOU DIRECTLY TO AXE ONLY SEQUENCING. SO WE HAD THESE SAMPLE, OUR INITIAL TOOL WAS TO USE A CHROMOSOMAL MICRO ARRAY TO LOOK FOR SOME MICROSCOPIC CHANGES IN CHROMOSOMAL STRUCTURE, WE ESSENTIALLY REPEATED WHAT JONATHAN AND MIKE DID IN 2007, AND WE PUBLISHED SEVERAL PAPERS, ONE IN 2011, ANOTHER ONE IN 2015 2015, SHOWING THAT WE COULD GET EXACTLY THE SAME RESULTS, WHICH BY THE WAY IN PSYCHIATRIC GENETICS IS NOT A TRIVIAL THING TO DEMONSTRATE. NOW IT IS, BUT EVEN AT THAT TIME, SORT OF THE FIELD SPENT MORE TIME ARGUING ABOUT WHY WE COULDN'T REPLICATE THAN ACTUALLY BEING ABLE TO MOVE FORWARD AND REPLICATE PRECISELY THE SAME RESULTS. SO WE FOUND THAT THERE WAS AN EXCESS RATE OF DE NOVO COPY NUMBER VAIR YITION IN KIDS WITH AUTISM VERSUS THOSE WITHOUT. GREAT EXPERIMENT, BUT IF YOU REALLY WANT TO UNDERSTAND BIOLOGY, FINDING CHROMOSOMAL CHANGES IS CERTAINLY NOT AS VALUABLE AS FINDING INDIVIDUAL SINGLE BASE PAIR CHANGES IN INDIVIDUAL GENES, RIGHT? THAT WOULD REALLY BE SORT OF WHERE YOU WANTED TO HEAD. SO AS SOON AS WE WERE ABLE TO USE EXOME SEQUENCING TECHNOLOGY TO SEQUENCE ESSENTIALLY EVERY GENE IN THE GENOME, WE APPLIED THAT, DID EXACTLY THE SAME STUDY, AND THE STUDY IS, YOU LOOK AT THE DNA OF THE PARENTS, YOU LOOK AT THE DNA OF THE CHILDREN, YOU'VE GOT ONE AFFECTED IN ALMOST ALL THE FAMILIES WITH SIMONS, YOU HAD AT LEAST ONE UNAFFECTED CHILD AND IT'S VERY SIMPLE. YOU LOOK FOR SOMETHING THAT'S IN THE KIDS THAT'S NOT IN THE PARENTS. THE BASE RATE OF DN DE NOVO VARIATION WAS LOW, ESSENTIALLY ALL WE HAD TO DO WAS COUNT TO ONE, THEN YOU COULD ASK THE QUESTION, DOES THE DE NOVO MUTATION, IF THERE IS ONE, SHOW UP IN THE KID WITH AUTISM OR DOES IT SHOW UP IN THEIR UNAFFECTED SIBLING? IT'S A WONDERFULLY SIMPLE AND CONTROLLED EXPERIMENT. WE DID THAT WITH EXOME SEQUENCING AND FOUND THERE WAS AN INCREASED RATE OF DE NOVO POINT MUTATIONS IN KIDS WITH ASD VERSUS THEIR UNAFFECTED SIBLINGS. BUT WHAT WAS ALSO IMPORTANT WAS THAT IT WASN'T ALL DE NOVO MUTATIONS, R. IF YOU LOOK ON THIS TABLE TOWARDS THE LEFT, YOU LOOK AT SILENT DE NOVO MUTATIONS, MUTATIONS THAT AREN'T EXPECTED TO HAVE ANY IMPACT ON THE PROTEIN THAT THEY'RE ENCOLDING, ENCODING, AND WE SEE NO DIFFERENCE. IT'S ONLY WHEN YOU START TAKING A LOOK AT DE NOVO MUTATIONS THAT ARE PREDICTED TO HAVE AN IMPACT ON PROTEIN FUNCTION THAT YOU BEGIN TO SEE THIS INCREASED RATE IN AUTISM VERSUS WITHOUT, AND THE LARGEST DIFFERENCE ARE FOR THE MUTATIONS THAT WE WOULD THINK OF AS MOST DAMAGING. SO CANONICAL SUPPLIES SITE MUTATIONS, STOP MUTATIONS, SO PUTATIVE LOSS OF FUNCTION MUTATION LED TO THE BIGGEST EFFECT. THAT INITIAL GRAPH UP THERE WAS PUBLISHED IN 2012, STEFFAN SANDERS WAS THE LEAD AUTHOR, AND THAT WAS AT ABOUT 200 FAMILIES, WE WERE ABLE TO SEE THE EFFECT, AGAIN SUGGESTING THAT THE EFFECT SIZE IS PRETTY BIG HERE, AND THEN THE FIGURE ON THE BOTTOM IS NOW AT 2500 FAMILIES, SO 10 TIMES AS MANY, AND ALL I WANT YOU TO SEE IS THAT WE GOT THE SAME ANSWER. DOESN'T MATTER IF YOU LOOK AT 100, 2,000, 20,000. THERE'S AN INCREASED RATE OF DE NOVO PUTATIVE DAMAGING -- IF IN KIDS WITH AUTISM VERSUS KIDS WITHOUT. WHAT I WANT TO SHOW YOU HERE IS SOME COMBINED DATA. I GO BACK AND FORTH A LITTLE IN TIME BUT IT'S TO MAKE AN ADDITIONAL POINT. SO IF YOU SEE THIS GROUP DIFFERENCE BETWEEN THOSE WITH AND WITHOUT AUTISM, THERE ARE SEVERAL POSSIBLE EXPLANATIONS, RIGHT? ONE IS THIS MAY BE A FRAGILITY HYPER MUTABLE STATE FOR KIDS WITH AUTISM, SO THAT YOU WOULD HAVE INCREASED MUTATIONS BUT THEY COULD LAND PRETTY MUCH ANYWHERE. NOW THE FACT THAT YOU DON'T SEE THAT WITH SILENT MUTATIONS WOULD BEGIN TO ARGUE AGAINST THAT A LITTLE BIT. BUT IN ORDER TO REALLY NAIL THAT STORY, WE HAVE OTHER WAYS OF THINKING ABOUT THE DATA, SO THE NEXT GRAPH HERE ACTUALLY IS FROM LATER IN TIME, BUT IT'S USING WHOLE GENOME SEQUENCING TO LOOK FOR DE NOVO MUTATIONS SO WE'RE ABLE ESSENTIALLY TO SEQUENCE ABOUT ALL 3 BILLION BASE PAIRS. AND WHAT YOU CAN SEE IS THAT THERE'S NO DIFFERENCE IN THE OVERALL DE NOVO MUTATION RATE, WHETHER OR NOT YOU'RE LOOKING AT THE EXOME OR YOU'RE LOOKING ACROSS THE ENTIRE GENOME BETWEEN PRO BANDS AND SIBLES. IT SIBLINGS. SO WHATEVER IS GOING ON, IT'S NOT SORT OF THAT THERE ARE LOTS OF MUTATIONS BEING DISTRIBUTED THROUGHOUT THE GENOMES IN KIDS WITH AUTISM AND NOT IN KIDS WITHOUT AUTISM, THAT THE RATE OF DE NOVO MUTATION IS ABOUT THE SAME. THEN THE NEXT GRAPH IS ASKING THE QUESTION, WELL, MAYBE IT'S NOT JUST A SINGLE DE NOVO MUTATION, MAYBE YOU NEED TO HAVE A COUPLE OF BAD OR THREE OR FOUR OR FIVE, IT'S A MULTI-HIT KIND OF HYPOTHESIS ABOUT WHY THESE MUTATIONS WOULD BE BAD IN KIDS& WITH AUTISM VERSUS KIDS WITHOUT, SO WE ASKED THAT QUESTION AND THAT'S THE DISTRIBUTION OF MULTIPLE HITS IN AFFECTED KIDS ON TOP, UNAFFECTED SIBLINGS ON THE BOTTOM, THERE'S NO DIFFERENCE. SO WHAT YOU'RE SEEING HERE IS AN EXCESS RATE OF DAMAGING DE NOVO MUTATIONS, THERE'S NOT HYPERMUTABILITY, AND YOU DON'T NEED MANY OF THEM. SO WHAT THIS TELLS YOU IS THAT ONE BAD MUTATION THAT DAMAGE DASS A PROTEIN AND LANDS IN THE WRONG SPOT IS WHAT'S DRIVING OUR RATE OF INCREASING DE NOVO MUTATION IN KIDS WITH VERSUS KIDS WITHOUT. SO BEAUTIFUL THING, NOT ONLY THAT IT'S SIMPLE TO FIND THAT YOU ONLY HAVE TO COUNT TO ONE. I'M A CYTOGENETICIST SO COUNTING TO ONE IS SORT OF WHAT WE DO, I'M NOT A STATISTICIAN. BUT ONE OF THE GREAT THINGS STATISTICALLY ABOUT DE NOVO MUTATION IS THAT THE BASE RATE, AS I SAID, IS VERY LOW. RIGHT? SO WHEN YOU LOOK ACROSS THE GENOME, IF YOU'RE LOOKING FOR A DAMAGING DE NOVO MUTATION ACROSS THE CODING EXOME, AS I SAID, YOU WILL GET LESS THAN ONE PER GENERATION DAMAGING DE NOVO MUTATION IN UNAFFECTED PEOPLE. SO YOU CAN PRETTY QUICKLY BEGIN TO SEE WHETHER OR NOT YOU'VE GOT AN INCREASED RATE IN KIDS WITH AUTISM. SO THE BASE RATE IS VERY LOW. THAT ALSO GAVE US ACTUALLY SOME REAL STATISTICAL ADVANTAGE WHICH IS THE FOLLOWING. SO WHEN WE STARTED THIS, YOU KNOW, PEOPLE WERE THINKING ABOUT THESE FINDINGS AS SORT OF PSEUDOMENDELIAN, LIKE EITHER IT'S THERE OR IT'S NOT THERE AND YOU CAN INFER WHETHER OR NOT IT'S A PATHOLOGICAL EVENT. THE PROBLEM IS, IS THAT IT DOESN'T REALLY HOLD HERE. WELL, IT'S AT A LOW BASE RATE IN TYPICAL INDIVIDUALS, YOU FIND DE NOVO MUTATIONS IN TYPICAL INDIVIDUALS, RIGHT? SO IF YOU JUST SEE ONE, THAT DOESN'T TELL YOU WHETHER OR NOT YOU'VE GOT AN AUTISM GENE. IF YOU SEE TWO, I DON'T KNOW, MAYBE IT DOESN'T. IF YOU SEE THREE, IF YOU SEE FOUR. SO WE ASKED THE QUESTION, HOW DO œSTATISTICAL FRAMEWORK THAT ALLOWS US TO KNOW? HOW MANY TIMES DO YOU NEED TO SEE THE SAME GENE HIT BY A -- TO HAVE ANY CONFIDENCE THAT YOU'RE SEEING SOMETHING THAT WOULD BE NOT EXPECTED BY CHANCE? SO THE KEY HERE IS THAT THE GENOME IS A BIG PLACE THAT YOU GET ESSENTIALLY LESS THAN ONE SHOT AT IT FOR A DAMAGING DE NOVO MUTATION PER GENERATION, RIGHT? SO YOU CAN DO A SLIGHT TWIST ON SORT OF THE TYPICAL SORT OF BURDEN TEST, INSTEAD OF JUST SAYING HOW MANY DE NOVO MUTATIONS ARE IN CASES, HOW MANY ARE IN CONTROLS, LET'S ADD THEM UP AND DO A T TEST. WE ASKED A SLIGHTLY DIFFERENT QUESTION. WE SAID GIVEN THE TARGET, GIVEN WHAT WE KNOW ABOUT THE RATE OF DE NOVO MUTATION, HOW LIKELY IS IT YOU'RE GOING TO ROLL THE SAME NUMBER TWICE, WHEN BASICALLY YOU HAVE 20,000 SIDES, RIGHT? SO HOW LIKELY, IF YOU SEE A DE NOVO MUTATION THAT'S DAMAGING IN GRIN 2B, IF YOU SEE A SECOND ONE, HOW LIKELY IS THAT BY CHANCE, WHAT IF YOU SEE A THIRD OR FOURTH? REALLY, WHEN YOU THINK ABOUT THAT, IT IS EITHER LIKE ROLLING DICE, SOMETIMES I USE A PICTURE OF LIGHTNING HERE. THE BASE RATE IS SO LOW THAT ACTUALLY SEEING LIGHTNING STRIKE TWO, THREE, FOUR TIMES GIVES YOU A TREMENDOUS AMOUNT OF STATISTICAL POWER. WE CREATED THE STATISTICAL FRAMEWORK WHICH ACTUALLY HAS HELD UP QUITE WELL NOW, PEOPLE HAVE USED SOMEWHAT DIFFERENT APPROACHES BUT NOW I THINK THE FIELD GENERALLY AGREES THAT IT'S A REVELTIVELY RELATIVELY SMALL NUMBER OF EVENTS AND YOU CAN USE A STANDARD APPROACH AND GET A P VALUE AND DIRECT BY ALL OF YOUR COMPARISONS OR USE AN FDR LIKE WE DO, BUT WE STARTED TO BE ABLE NOW TO STRATIFY AND GIVE PEOPLE LISTS OF GENES THAT NOT ONLY TELL YOU WHAT GENES HAVE BEEN IDENTIFIED BUT GIVE YOU A REALLY STRONG STATEMENT ABOUT HOW LIKELY IS THAT A CHANCE OBSERVATION? THIS IS FROM THAT 2015 PAPER, UP ON THE TOP OVER THERE ARE THE THE COPY NUMBER VARIATIONS, REGIONS OF THE GENOME, BUT NOW IMPORTANTLY WE ALSO HAVE SPECIFIC GENES. AND THIS GROUP OF GENES HAS A FALSE DISCOVERY RATE OF LESS THAN .01, THAT IS ESSENTIALLY EQUIVALENT TO A GENOME-WIDE SIGNIFICANT HIT FROM GENOME WIDE ASSOCIATION STUDIES, AND IS THE GROUP THAT PEOPLE WOULD SAY THESE ARE DEFINITIVE AUTISM GENES. IT'S STILL PROBABILITIES, IT'S STILL STATS BUT WHEN YOU GET TO A FALSE DISCOVERY RATE OF LESS THAN .01 IT'S ACCOUNTING FOR ALL OF THE COMPARISONS THAT WE'RE DOING. YOU CAN HAVE VERY HIGH CONFIDENCE THAT THESE RIN CREASING RISK FOR ASD. IF YOU WANT TO MAKE A MOUSE OR MARMOSET, MY SUGGESTION WE'D PROBABLY STAY ON THAT SIDE OF THE TABLE, BUT IF YOU WANT TO DO AN INFORMATICS STUDY, YOU MAY MOVE ALL THE WAY OVER AND DECIDE I WANT TO TAKE THE ENTIRE SET OF YEENS GENES THAT HAS AN FDR OF LESS THAN .1, SO WE LAID OUT A TABLE THAT GAVE YOU MORE THAN THE STRICTEST THRESHOLD FOR STATISTICS SO THAT PEOPLE CAN MAKE A DECISION ABOUT WHAT THEY WANT TO DO AND HOW THEY WANT TO LEVERAGE THESE THINGS. SO THIS IS SORT OF WHERE THINGS STAND. I CAN LEAVE IT FOR A SECOND AND LET YOU -- BUT ACTUALLY IF YOU'RE INTERESTED, WHAT WE DID IS, BECAUSE THE STATISTICAL FRAMEWORK HOLDS UP VERY NICELY, BY THE WAY, I REALLY HAVE TO MAKE THE POINT THAT THERE WERE FOUR OR FIVE LABS SIMULTANEOUSLY WORKING ON THIS AROUND THE COUNTRY, AND SO WE HAVE MULTIPLE PAPERS FROM OUR LAB BUT ALSO MARK DALEY AT THE BROAD, EVEN IN WASHINGTON AND MIKE WIGLER AT COLDSPRING HARBOR, THIS IS ALL CUMULATIVE WORK THAT HAS ENDED UP IN GIVING US NOW THIS RELIABLE APPROACH TO GENE DISCOVERY USING DE NOVO MUTATIONS. I JUST WANT TO POINT OUT THAT NOW THE REASON THAT THIS TOOK SO LONG, WE WILL TO WAIT UNTIL 2017 TO HAVE THE FIRST PAPER SHOWING THIS IN TOURETTE'S SYNDROME, SO ABOUT FIVE YEARS BEHIND, AND IT'S SIMPLY A MATTER OF THE FACT THAT WE DIDN'T HAVE THE PATIENTS, DIDN'T HAVE THE PATIENT COHORTS, NOW THAT WE DO, WE SEE EXACTLY THE SAME THING WITH AN EXCESS OF DE NOVO DAMAGING MUTATIONS IN KIDS WERE TOURETTE VERSUS THOSE WITHOUT, AND WE CAN BEGIN TO DO EXACTLY THE SAME THING WE'RE DOING IN ASD. THE EFFECT SIZE IS SOMEWHAT SMALLER, SO IT'S GOING TO TAKE A LARGER NUMBER OF KIDS TO ACTUALLY GET TO AN FDR OF THE Q VALUE OF LESS THAN .01, ACTUALLY WE'VE ADDED ABOUT 300 FAMILIES SINCE THIS WAS PUBLISHED IN MAY, AND NOW THE GENE CSLR3 HAS CROSSED THAT THRESHOLD TO BE WHAT YOU CONSIDER TO BE, I THINK, A DEFINITIVE TOURETTE GENE. SO THIS IS KIND OF WHERE GENE DISCOVERY STANDS WITH REGARD TO AUTISM AND TOURETTE, LOOK AT LARGE EFFECT DE NOVO MUTATIONS. THE BLUE BOX JUST TO GIVE YOU A SENSE OF SCALE THAT I'M GOING TO COME BACK TO, THOUGH THOSE GENES ON AVERAGE CARRY ABOUT A 20 FOLD INCREASE IN RISK RELATIVE TO NOT HAVING THE MUTATION. THOSE RANGE, SOME OF THEM, THE MOST COMMON THAT WE SEE OF CHROMATIN HELA CASE DOMAIN CHD CHD8 HAS EFFECT SIZES SOMEWHERE NORTH OF 50 FOLD INCREASE IN RISK, SODIUM CHANNEL, SAME THING, BUT AS A GROUP, 20 FOLD INCREASE IN RISK. I'M GOING TO COME BACK TO SORT OF HOW TO THINK ABOUT HOW BIG THAT RISK IS, BUT WHAT I WANT TO TALK TO YOU ABOUT IS THAT SO WE FOUND THESE DE NOVO LOSS OF FUNCTION MUTATIONS IN AUTISM, DEPENDING UPON HOW YOU DO THE CALCULATION, WE BELIEVE IT ACCOUNTS FOR SOMEWHERE AROUND 15% BETWEEN THE COMB SOMOL CHROMOSOMAL CHANGES AND POINT MUTATIONS OF KIDS YOU WOULD SEE IN AN ASD CLINIC. SO WITHOUT ASCERTAINING FOR MORPHOLOGY OR INTELLECTUAL DISABILITY, YOU SHOULD HAVE A YIELD OF ABOUT 15%. IF YOU LOOKED AT GIRLS, THAT NUMBER WOULD GO UP. IF YOU LOOKED AT GIRLS WITH INTELLECTUAL DISABILITY, THE PERCENTAGE WOULD GO UP HIGHER, IF YOU LOOKED AT GIRLS WITH INTELLECTUAL DISABILITY AND EPILEPSY, 40, 50% OF THE GROUP YOU WOULD SEE IN CLINIC ASCERTAINED THAT WAY WOULD HAVE A DE NOVO EITHER COPY NUMBER VARIATION OR DAMAGING POINT MUTATION. BUT WHEN YOU READ PAPERS ABOUT AUTISM, THEY WILL TELL YOU CORRECTLY THAT THE LION'S SHARE OF POPULATION RISK FOR AUTISM IS NOT IN THE KIND OF MUTATIONS THAT I'VE IDENTIFIED OR THAT WE'VE IDENTIFIED, BUT IN COMMON SMALL EFFECT ALLELES. THE HIGHLY POLYGENIC, AND THAT ONLY ABOUT 3% OF THE OVERALL RISK FOR AUTISM IS CARRIED IN RARE VARIANTS. AND THAT OFTEN IS CONFUSING TO PEOPLE SO I WANT TO EXPLAIN HOW BOTH OF THOSE THINGS CAN BE TRUE SIMULTANEOUSLY. SO THEY CAN BE TRUE SIMULTANEOUSLY BECAUSE WHEN YOU THINK ABOUT POPULATION RISK, ONE OF THE THINGS THAT YOU HAVE TO REMEMBER IS THE WAY THAT WE DIAGNOSE THINGS IN PSYCHIATRY. WE HAVE A POPULATION OF PEOPLE WITH BEHAVIOR AND THEN WE DRAW A LOON WHEN THERE'S A CLUSTER OF BEHAVIORAL SYMPTOMS THAT ARE BAD ENOUGH EITHER TO WARRANT CLINICAL ATTENTION AND FOR US TO DECIDE THAT THEY CON FIR IMPAIRMENT IN CONFER IMPAIRMENT IN THESE DOMAINS. THE FIRST THING YOU CAN SEE IS THAT THE VAST MAJORITY OF GENETIC RISK WILL NEVER GO PAST THAT THRESHOLD, RIGHT? SO THE VAST MAJORITY OF POPULATION RISK IS IN PEOPLE WHO RUN AFFECTED, WHO WILL NEVER COME TO CLINIC, SO WHEN I SAY IT'S 15 OR 20 OR 40%, WHAT I'M TELLING YOU IS THAT IF THEY GET TO CLINIC, 15% OF THEM OR 20% OF THEM OR 40% OF GIRLS WITH EPILEPSY AND INTELLECTUAL DISABILITY IN AUTISM WILL HAVE MUTATIONS BECAUSE WE'VE ALREADY SELECTED FOR THE TAIL OF THE DISTRIBUTION WHERE A LOT OF OUR RISK IS GOING TO RESIDE, SO MOST OF THE RISK LANDS IN PEOPLE WHO ARE NOT AFFECTED, SO THOSE ARE CLINICALLY AFFECTED AND THEN THE SECOND THING IS THAT THESE DE NOVO MUTATIONS ARE HAPPENING ON THE BACKGROUND OF THIS RISK THAT'S PLAYING OUT IN FAMILIES, AND WHAT'S HAPPENING IS IT'S NOT LIKE A MENDELIAN DISORDER LIKE HUNTINGTON'S DISEASE WHERE IF YOU DON'T HAVE THE MUTATION, YOU HAVE NO RISK AND IF YOU HAVE THE MUTATION, YOU HAVE THE RISK. THESE ARE DE NOVO MUTATIONS IN FAMILIES ALREADY CARRYING POP LITION RISK POPULATION RISK, AND IT'S MOVING A KID IN THAT FAMILY WHO HAS THE MUTATION FROM WHEREVER THEY WOULD HAVE BEEN OVER, SHIFTING THEM TOWARDS THE DIAGNOSTIC THRESHOLD. SO YOU CAN GET THIS DRAMATIC OVERREPRESENTATION FROM A VERY SMALL PERCENTAGE OF THE POPULATION RISK BECAUSE YOU HAVE LARGE EFFECT SIZES THAT ARE TAKING PEOPLE WHO OTHERWISE WOULD HAVE BEEN IN THE MIDDLE OF THIS DISTRIBUTION AS A FAMILY AND THEN MOVING THEM OVER ON THE AFFECTED SIDE. THEN THE ONLY OTHER THING THAT I WANT TO SHOW YOU IS THAT THAT CAN LEAD TO SOME CASES WHERE YOU HAVE A LARGE EFFECT DE NOVO MUTATION AND IF YOU HAVE IT IN THE RIGHT FAMILY, YOU'RE NOT GOING TO SEE ANYTHING. SO AGAIN, THESE ARE NOT MENDELIAN. THEN THE LAST THING THAT I WANT TO SHOW YOU IS VERY INTERESTINGLY -- AND I'M GOING TO COME BACK TO IT WHEN I -- I'M GOING TO SHIFT NOW TO MECHANISMS, IS THAT IT'S FASCINATING AND EXTREMELY CHALLENGING THAT WHILE EVERYTHING I TOLD YOU IS TRUE, I COULD HAVE TOLD YOU VERY MUCH THE SAME STORY WITH REGARD TO INTELLECTUAL DISABILITY, EPILEPSY, TO SOME DEGREE SCHIZOPHRENIA, NOT ONLY THE SAME STORY WITH REGARD TO GENETIC ARCTIC TEU I COULD HAVE PICKED ONE GENE AND TOLD YOU A STORY THAT IT DIDN'T LEAD TO AUTISM BUT IT LED TO EPILEPSY WITHOUT AUTISM, OR IT LED TO SCHIZOPHRENIA WITH NO EVIDENCE OF AT LEAST PREMORBID SOCIAL DISABILITY. SO WHAT WE'RE SEEING ARE LARGE EFFECT GENES WHERE THERE'S A TREMENDOUS OVERLAP, THERE'S TREMENDOUS KIND OF BIOLOGICAL PHENOTYPIC PHEOTROPY -- CAN LEAD YOU NOT ONLY TO HAVE DRAMATICALLY INCREASED RISK FOR AUTISM BUT ALSO DRAMATICALLY INCREASED RISK FOR A RANGE OF OTHER NEURODEVELOPMENTAL SYNDROMES. SO WE SEE NOT NO SPECIFICITY, WE JUST SEE VERY LITTLE SPECIFICITY AND WE DON'T HAVE THE NUMBERS YET TO BE ABLE TO TELL YOU SO THIS GENE MAY LEAD TO BOTH EPILEPSY IN SOME CASES AND AUTISM IN OTHERS, CAN WE BEGIN TO TELL YOU HOW OR WHY THAT DISTRIBUTION HAPPENS. BUT THE FIRST ORDER APPROXIMATION IS THAT THERE'S TREMENDOUS VARIABILITY IN THE OUTCOME OF GENES THAT HAVE VERY LARGE EFFECTS BUT ARE NOT SPECIFIC FOR ONE NEURODEVELOPMENTAL DISORDER. SO THAT'S WHERE WE ARE WITH AUTISM AND TOURETTE'S SIM SIN DROME WITH REGARD TO GENE DISCOVERY, NOW WHAT DOES THAT MEAN IN GETTING FROM GENES TO MECHANISMS? I WANT TO CONTRAST WHAT'S GOING ON IN NEURODEVELOPMENTAL DISORDERS TO WHAT'S GOING ON IN MANY AREAS OF PSYCHIATRIC AND MANY OTHER COMPLEX DISEASES. ALL THE WORK I'VE SHOWED ABOUT PROGRESS WITH REGARD TO AUTISM HAS ALL BEEN ABOUT RARE DE NOVO MUTATIONS. I DIDN'T SHOW YOU A GWAS. THE REASON I DIDN'T IS THAT IN AUTISM SO FAR NOW WE FINALLY HAVE ONE ALLELE THAT HAS COME OUT OF A GWAS STUDY NOW OF ABOUT 10,000 PEOPLE. SO BEFORE THAT, WE HAD NONE UP UNTIL ACTUALLY ABOUT SIX MONTHS AGO, I JUST SAID THERE ARE NO GWAS HITS TO SHOW YOU, BUT THERE'S A FUNDAMENTAL DIFFERENCE BETWEEN WHAT WE'VE BEEN DOING AND WHAT GENOME WIDE ASSOCIATION DOES, WHICH IDENTIFIES COMMON VARIANTS TRANSMATED MITTED FROM GENERATION TO GENERATION THAT HAVE SMALL EFFECTS. WE'RE LOOKING FOR DE NOVO MUTATIONS THAT MAY OR MAY NOT BE TRANSMITTED FROM GENERATION TO GENERATION THAT MAY HAVE VERY LARGE EFFECTS. SO I WANT TO POINT OUT THAT THOSE THINGS PRESENT DIFFERENT -- I'M GOING TO HAVE A SLIDE NOW THAT SAYS PICK YOUR POISON. WE BOTH HAVE OUR CHALLENGES BUT THEY'RE QUITE DIFFERENT. I THINK THERE'S A TENDENCY IN& THE FIELD NOW TO THINK ABOUT THE SORT OF CHALLENGE IN PSYCHIATRIC GENOMICS OF MOVING FROM GENE TO THERAPY OR GENE TO PATHOPHYSIOLOGY AS SORT OF ONE SIZE FITS ALL, AND IN FACT, THEY'RE QUITE DIFFERENT. SO Q.US THIS IS WHAT'S CALLED THE MANHATTAN PLOT FROM GENOME WIDE ASSOCIATION. THIS IS LOOKING FOR COMMON ALLELES OF SMALL EFFECT, THEY HAVE THIS ENORMOUS HIT HERE, I THINK ERIC LANDER CALLED IT THE FREEDOM TOWER OF SCHIZOPHRENIA GENETICS. THAT'S A P VALUE. ALL THAT'S TELLING YOU IS THAT THAT'S DIFFERENT IN CASES FROM CONTROLS, THAT TELLS YOU NOTHING ABOUT WHAT IMPACT THAT'S HAVING IN CASES VERSUS CONTROLS AND THAT'S THE IMPACT IT'S HAVING IN CASES VERSUS CONTROLS. SO THIS IS CALLED POLYGENIC RISK AND YOU CAN SUM THE NUMBER OF HITS THAT YOU HAVE FROM ABOUT 100, 150 NOW ACTUALLY THERE ARE MORE COMMON ALLELES WITH SMALL EFFECT, AND ULTIMATELY IF YOU'RE CARRYING 150 OUT OF THE 150 THAT HAVE BEEN IDENTIFIED, YOU'RE GOING TO HAVE BIG RISKS. IF YOU HAVE 150 VARIATIONS THAT ARE CONTRIBUTING FROM GWAS, THEN YOU'RE GOING TO EQUAL ABOUT THE EFFECT SIZE OF ONE OF THE SINGLE MUTATIONS THAT I JUST IDENTIFIED FOR YOU. BUT IF YOU HAVE THIS ALLELE, THIS IS THE C4 ALLELE, BEAUTIFUL GENETICS, AND THEN A NICE STUDY SHOWING THAT THAT POTENTIALLY COULD BE RELATED TO SYNAPTIC PRUNING. BUT FROM A BIOLOGICAL STANDPOINT, HAVING THAT ONE ALLELE IF THAT'S ALL YOU HAD WOULD TAKE YOU FROM HAVING A 1% CHANCE OF HAVING SCHIZOPHRENIA -- IT TAKES YOU ACTUALLY TO 1.27% CHANCE. SO THE DIFFERENCE BETWEEN HAVING A 20 OR 50 OR 70 FOLD INCREASE IN RISK AS A CONSEQUENCE OF A DE NOVO MUTATION VERSUS HAVING SOMETHING THAT ESSENTIALLY DOES NOT BY ITSELF MOVE THE NEEDLE BIOLOGICALLY WITH RARTD REGARD TO RISK, IF YOU HAVE THIS MUTATION -- WHEN PEOPLE SAY MAYBE THIS IS A TWO-HIT MODEL, IT'S NOT. IT MAY BE A 150-HIT MODEL BUT IT'S NOT A TWO-HIT MODEL. AND THAT IS REALLY ONE OF THE BIG CONCEPTUAL DIFFERENCES AND CHALLENGES AROUND HOW DO YOU THINK ABOUT MOVING FROM GENES TO BIOLOGY WITH GWAS, VERSUS LOOKING AT DE NOVO MUTATIONS, RARE VARIANTS OF LARGE EFFECTS, SO FOR GWAS, HUNDREDS OF MUTATIONS, AND WHEN YOU THINK ABOUT MODELING THEM, YOU WOULD HAVE TO THINK THAT THERE'S AN IMPORTANT QUESTION, IF YOU MODEL BIOLOGICAL PROCESS, I'M NOT REALLY SURE HOW THAT ONE THING IS INTERPRETABLE WITH REGARD TO HUMAN PATHOPHYSIOLOGY. ULTIMATELY YOU MIGHT BE ABLE TO LINK THAT TO PATHOPHYSIOLOGY IF YOU KNOW MORE ABOUT IT, BUT I THINK IT'S VERY CHALLENGING. SO I THINK PEOPLE ARE THINKING HOW CAN WE PUT IN DOZENS OF MUTATIONS IN STEM CELLS SIMULTANEOUSLY? YOU CAN THINK THAT'S PRETTY SIGNIFICANT CHALLENGE. SO I'M RAISING THE SAME QUESTION, WHAT CAN YOU RELIABLY MODEL THERE, HOW YOU THINK ABOUT DOING IT, I THINK IS A BIG ISSUE. ANOTHER ISSUE IS ARE YOU STUDYING ETIOLOGY, EVEN THOUGH IT'S GENETICS, PEOPLE OFTEN EQUATE GENETICS WITH ETIOLOGICAL PROCESSES, BUT YOU DON'T KNOW IF YOU'RE LOOKING AT ETIOLOGY OR YOU'RE LOOKING AT COURSE MODIFIERS, BECAUSE PART OF WHAT'S GOING TO HAPPEN IS SOMEONE IS GOING TO COME THAO YOUR INTO YOUR STUDY, THESE ARE CLINICAL STUDIES, SO THEY'RE GOING TO COME INTO YOUR STUDY IN PART BECAUSE OF HOW THEIR SCHIZOPHRENIA PLAYED OUT. MAYBE THAT ALLELE HAS A TINY IMPACT ON HOW YOU RESPOND TO MEDICATIONS, AND IF YOU'RE LESS LIKELY TO RESPOND TO MEDICATIONS, YOU'RE MORE LIKELY TO END UP IN A GENETIC STUDY. MAYBE IT HAS -- IT'S THE HUNDREDTH THING THAT NEEDS TO GO WRONG IN TERMS OF BUFFERING FROM AN ETIOLOGICAL PROCESS. SO I'M NOT SUGGESTING THAT WE KNOW THAT, ALL THAT I'M SAY BEING IS THAT AS YOU START TO TRY TO DIG IN TO GENES TO BIOLOGY, THAT THERE ARE SIGNIFICANT CHALLENGES WITH REGARD TO THAT MODEL. THAT'S NOT TO SAY THERE ARE VERY SIGNIFICANT CHALLENGES AS WELL WITH REGARD TO DE NOVO MUTATION. THE FIRST IS EVERYONE ALWAYS ASKS, WHAT IF YOU HAVE CHD8 MUTATION, WHAT DOES THE PHENOTYPE LOOK LIKE? IN THE WORLD, I THINK WE'VE GOT 10 OR 12 CHD8 MUTATIONS IN PATIENTS, SO THE POWER TO DO GENOTYPE PHENOTYPE WITH THESE RARE MUTATIONS IS ESSENTIALLY NIL. WE TRY TO SOME OF THE CMVs, KE WITH GET A LITTLE TRACTION BUT IT'S QUITE DIFFICULT AT LEAST AT THIS POINT, THERE ARE NEW STUDIES BEING DEVELOPED USING VERY LARGE CLINICAL DATABASES WHICH I THINK ARE GOING TO BE VERY PROMISING BUT FROM THE CURRENT RESEARCH COHORTS, VERY HARD TO DO GENOTYPE PHENOTYPE. FOR ASD AND I THINK FOR THESE OTHER DISORDERS, A LACK OF SPECIFICITY LEADS PEOPLE TO SAY YOU HAVE A BIG EFFECT BUT IT'S A BIG EFFECT ON WHAT? SO MAYBE THE GENES THAT YOU'RE FINDING ARE REALLY ABOUT JUST OVERALL COGNITIVE DYSFUNCTION, WHAT PEOPLE USED TO KIND OF NOT SO NICELY JUST CALL BAD BRAIN, AS OPPOSED TO UNDERSTANDING SOMETHING SPECIFIC ABOUT THE PATHOPHYSIOLOGY OF SOCIAL DISABILITY. IT'S A DIFFICULT QUESTION. COY DO AN HOUR ON WHY I THINK THERE'S TRACTION ON BOTH BUT WE'LL HAVE TO SAVE THAT FOR ANOTHER DAY OR FOR QUESTIONS. I THINK ONE OF THE BIGGEST PROBLEMS I'M GOING TO SPEND THE NEXT FIVE OR 10 MINUTES TALKING MINUTES FOR QUESTIONS IS THIS POINT. I MADE IT IN THE INTRODUCTION. ONE OF THE FIRST THINGS THAT DAWNED ON ME WHEN WE -- AFTER 12 YEARS OR 15 YEARS OF TRYING TO FIND GENES, WAS HOW SIMPLISTIC MY NOTION WAS OF WHAT I WAS GOING TO DO ONCE I FOUND THEM. I WAS NEXT DOOR TO RICK WHO HAD DONE THIS IN THE KIDNEY WITH HYPERTENSION, IT JUST LOOKED SO BEAUTIFULLY STRAIGHTFORWARD. FIND THE GENE, FIND THE MECHANISM, FIND THE PATHWAY, TARGET THE PATHWAY, FIX THE PROBLEM. BUT THERE WERE A COUPLE THINGS THAT SORT OF EMBARRASSINGLY I DIDN'T TAKE INTO ACCOUNT AND SOME OF IT BECAME REALLY UNDER DND SCORED ONCE WE STARTED SEEING WHAT THESE GENES WERE, SO ALMOST EVERY GENE WE FOUND WAS HIGHLY BIOLOGICALLY PEDIATRICIAN YA TROA PIP PIK. TROPIC. YOU CAN SIGN SOMETHING TO THE GENE, BUT -- DOING MANY THINGS IN DEVELOPMENT. SO THEY NOT ONLY ARE KIND OF BIOLOGICALLY PLEA OWE PRO TICK PIK, THEY'RE HIGHLY -- IT BECOMES VERY DIFFICULT, YOU CAN -- WHEN YOU HAVE A 20 OR 50 FOLD INCREASE IN RISK BECAUSE YOU HAVE LOSS OF FUNCTION MUTATION, I CAN PRETTY MUCH GUARANTEE YOU IF YOU MESS WITH THAT GENE AND LOOK IN ENOUGH MODEL SYSTEMS, YOU'RE GOING TO SEE SOMETHING, BUT THE QUESTION IS, IS THAT THING RELATED TO WHAT YOU CARE ABOUT WITH REGARDS TO THE PATHOPHYSIOLOGY OF AUTISM? I DON'T THINK THAT THERE'S AN OBVIOUS ANSWER THERE, RIGHT? THIS WAS UNDERSCORED, THE FIRST GENE WE DISCOVERED IN THE LAB AND HAD REAL CONFIDENCE IN WAS THE SODIUM CHANNEL. STEVE WAXMAN WAXMAN IS THE WORLD EXPERT IN SOME SEWED YUM CHANNEL, I RAN DOWN THERE WITH A POSTDOC, SO EXCITED WE WERE GOING TO HAND HIM OUR FIRST REAL HIGH COMPETENCE AUTISM GENE. HE LOOKED SO INCREDIBLY UNIMPRESSED, I COULD BARELY GET HIM TO LOOK UP FROM HIS DESK. ULTIMATELY HE TURNED TO ME AND SAID YEAH, THAT'S INTERESTING BUT UNLESS YOU TELL ME WHAT CELL TYPE I'M MODELING THIS IN, I HAVE NO IDEA WHAT I CAN DO FOR YOU BECAUSE IF I PUT IT IN -- I CAN GIVE YOU COMPLETELY OPPOSITE ELECTROPHYSIOLOGICAL PHENOTYPES. AND BY THE WAY WHILE YOU'RE AT IT, YOU'RE GOING TO HAVE TO TELL ME WHEN IN DEVELOPMENT YOU NEED TO LOOK AT THIS BECAUSE SCN2A HAS FIVE OR SIX DIFFERENT FUNCTIONS DEPENDING UPON WHEN YOU LOOK AT IT IN DEVELOPMENTAL TIME. SO I BECAME VERY KIND OF PREOCCUPIED THEN WITH THE -- SO MY FIRST REACTION WAS, THAT'S IMPOSSIBLE. I CAN'T TELL YOU WHEN AND WHERE TO LOOK FOR THESE GENES. THEN I DECIDED MY LAB WAS GOING TO TURN IN THE DIRECTION OF TRYING TO FIGURE OUT WHEN AND WHERE. BUT IT GETS TO THIS IDEA THAT SEEING BIOLOGY IS NOT NECESSARILY UNDERSTANDING PATHOPHYSIOLOGY. BUT SEEING BIOLOGY ACTUALLY FOR THESE GENES IS PRETTY STRAIGHTFORWARD, SO WHEN YOU LOOK AT THE GENES FOR AUTISM, THEY FALL OUT VERY QUICKLY INTO -- IT DOESN'T INCLUDE EVERY GENE, BUT BY KIND OF OVERT -- YOU KNOW, THESE ARE THE THINGS THAT WE'VE ALREADY ASSIGNED AS FUNCTION, THERE'S A HUGE GROUP OF THEM THAT FALL INTO SYNAPTIC FUNCTION AND THERE'S ANOTHER GROUP THAT FALL NOOSE CHROMATIN MODIFICATION AND EPIGENETIC REGULATION. THERE ARE OTHERS, BUT ALMOST IN THAT FIRST GROUP, ALMOST HALF FALL INTO ONE OR THE OTHER AND THEN THERE ARE A FEW STRAGGLERS. AGAIN, PART OF THE CHALLENGE HERE IS THAT THAT'S GREAT, MAN, AFTER YEARS OF NOT BEING ABLE TO FIND A SINGLE GENE FOR AUTISM, IT'S PRETTY FUN TO BE ABLE TO DRAW THESE DIAGRAMS AND START SHOWING YOU WHERE THESE DIFFERENT GENES ARE, BUT THE FLIP SIDE IS THAT YOU COULD ALSO INTERPRET THIS AS SORT OF THE MOST EXPENSIVE PENETRATING GLIMPSE INTO SCIENTIFIC HISTORY BECAUSE NOW WHAT I'VE GOT IS A GLEUP OF GROUP OF GENES INVOLVED IN NEURAL AND A GROUP INVOLVED IN DEVELOPMENT. IT'S OBVIOUSLY KIND OF A FLIPPANT WAY TO DESCRIBE IT. I THINK IT DOES GET TO SORT OF A CRITICAL PROBLEM HERE WHICH IS AS YOU START TO TRY TO PULL ON THIS, IT'S SORT OF A VERSION OF WHAT STEVE WAXMAN WAS TALKING ABOUT, YOU'RE BASICALLY LOOKING AT ALL OF NEURODEVELOPMENTAL BIOLOGY, SO HOW IN THE WORLD DO YOU GO FROM SOMETHING LIKE THIS TO AN UNDERSTANDING OF PATHOPHYSIOLOGY? AGAIN, THIS WAS MY SIMPLISTIC IDEA, I SHOWED THIS DIAGRAM FOR ABOUT 15 YEARS UNTIL I SUDDENLY HAD DISCOVERED A GENE AND REALIZED THAT IT WASN'T GOING TO WORK, AS A CHILD PSYCHIATRIST, VERY EMBARRASSING BECAUSE IT DOESN'T HAVE EITHER DEVELOPMENT OR BRAIN IN THE MODEL, THIS IS HIGHLY STATIC FIND THE GENE, I THOUGHT THE CONVERGENCE WAS GOING TO BE AT THE MODEL OF MOLECULAR PATHWAY, AND WHEN YOU THINK ABOUT HOW COMPLEX THE BRAIN IS, WHO KNOWS WHETHER OR NOT THAT'S WHERE THE POINT OF CONVERGENCE IS? SO AS I SAID IN ABOUT 2012, WHEN WE HAD OUR FIRST AUTISM GENE, AFTER RUNNING DOWN THE HALL TO SEE STEVE WAXMAN, I RAN DOWN THE HALL TO SEE ANOTHER COLLABORATOR AT YALE. ANAD WAS TRYING TO BUILD MAPS OF THE TRANSCRIPTOMIC TRAJECTORY OF DEVELOPING HUMAN BRAIN. HE WAS TRYING TO UNDERSTAND WHAT IS THE SPATIAL AND TEMPORAL DISTRIBUTION OF GENE EXPRESSION UST BY LOOKING AT POST MORE TOM POSTMORTEM BRAINS THAT TURNED INTO SOMETHING CALLED THE BRAIN SPAN PROJECT. IT STRUCK ME, MAYBE THIS IS A WAY TO BEGIN TO ASK THE QUESTION WHEN AND WHERE. WE HAVE A VET SETH OF A SET OF GENES WE KN OW LEAD TO AUTISM. THEY OVERTLY HAVE VERY DIFFERENT FUNCTIONS, SOME CHROMATIN, SOME SYNAPSE, SOME IN THE POST SYNAPTIC DENSITY, SOME SCAFFOLDING PROTEINS, ET CETERA, THEY'RE ALL DIFFERENT BUT WE KNOW THEY ALL LEAD TO AUTISM. SO WE HAVE BEEN -- EVEN IF THEY DON'T CONVERGE WITH REGARD TO OVERT FUNCTION, MAYBE THEY CONVERGE IN DEVELOPMENTAL TIME AND SPACE. MAYBE THE POINT IS NOT WHAT THEY DO, BUT WHEN AND WHERE THEY DO IT, RIGHT? SO WE ASKED THE QUESTION WHETHER OR NOT WE COULD TAKE THESE GENES THAT ALL ARE DIFFERENT FOR AUTISM AND SEE USING THE MAPS IN TIME AND SPACE TRANSCRIPTOMIC TRAJECTORIES WHETHER OR NOT THE POINT THAT THESE AUTISM GENES CONVERGE MORE THAN WE WOULD EXPECT BY CHANCE. SO WE TOOK BRAIN REGIONS AND ANAD MICRO DISSECTED 16 BRAIN REGIONS AND THEN HE LOOKED AT THE TRANSCRIPTOMIC PROFILE ESSENTIALLY ASSAYING EVERY GENE HOPEFULLY IN AS UNBIASED A WAY AS POSSIBLE ACROSS THE LIFESPAN FROM FOUR WEEKS OF GESTATION TO ABOUT 80 YEARS OF AGE. THESE ARE ARBITRARILY DRAWN INTERVALS OF TIME AND WHAT I'M SHOWING YOU BY PUTTING THAT BOX AROUND BIRTH IS WE ACTUALLY HAVE MUCH RICHER, MUCH DENSER DATA BEFORE BIRTH, FROM ZERO TO 80 IS THE SAME NUMBER OF TIME PERIODS AS FROM FOUR WEEKS TO GESTATION. SO WHAT WE DID IS WE TOOK HIS TRANSCRIPTOMIC DATA AND OUR GENETIC DATA AND THERE ARE A NUMBER OF DIFFERENT WAYS TO DO IT. THE WAY WE THOUGHT ABOUT DOING IT IS TO TAKE ALL THE GENES WE HAVE THAT WE KNOW ARE HIGH CONFIDENCE FOR AUTISM, THE 10 OF THEM, LET'S LOOK AT ALL THE GENES THAT ARE COEXPRESSED WITH THEM. THEY EITHER GO UP OR GO DOWN WITH THEM, INFERRING THAT THEY MAY SHARE FUNCTION, AND LET'S BUILD IN EVERY WINDOW IN SPACE AND TIME A COEXPRESSION NETWORK THAT'S SEATED BY THE GENES THAT WE KNOW ARE RELATED TO AUTISM, OKAY? SO THAT WILL TELL UL, YOU COULD ASK WHETHER OR NOT THOSE NETWORKS ARE TIGHTLY CONSTRUCTED, ET CETERA, I THINK WHAT IT BEGINS TO GIVE YOU, WHAT WE HOPE IT GAVE US WAS SOME SORT OF PICTURE OF THE KIND OF DYNAMIC TRANSSCRIPTOME AROUND THE GENES WE WERE INTERESTED IN, BUT THEN WHAT WE WANTED TO KNOW IS, IS THIS RELEVANT FOR AUTISM? SO WE HAD TO ASK A SECOND ORTHOGONAL QUESTION WHICH IS IF WE TOOK THE NEXT SET OF GENES, NOT THE 10 THAT SEEDED THE ANALYSIS BUT ALL THE GENES THAT HAD STATISTICAL EVIDENCE FOR AUTISM BUT FELL JUST SHORT OF THAT, SO WE FIGURED WE'RE ENRICHED FOR REAL AUTISM GENES THERE, NOW WE WANT TO ASK, DO THOSE GENES THAT WE DIDN'T USE IN ORDER TO SEE THIS ANALYSIS, DO THEY SHOW UP IN THESE COEXPRESSION NETWORKS, BECAUSE IF THEY DO, IT WOULD SUGGEST THAT MAYBE YOU'RE FINDING GENES BY THESE COEXPRESSION NETWORKS RELATED TO AUTISM RISK, AND SINCE THEE ARE DIVIDED BY SPACE AND TIME, YOU MIGHT SEE THIS KIND OF LIGHT UP LIKE A CHRISTMAS TREE ACROSS ALL DEVELOPMENTAL EP IXES IN ALL TIMES AND YOU'D BE S.O.L. BUT IN FACT, WHEN WE LOOKED, IT DIDN'T LIGHT UP EVERYWHERE. WE SAUL AN ENRICHMENT SAW ENRICHMENT OF TH ESE IN THESE TRANSCRIPTIONAL NETWORKS IN A COUPLE PLACES, THE RICHEST WAS MID FETAL DEVELOPMENT AND THAT'S BETWEEN ABOUT 14 AND 20 WEEKS OF GESTATION, AND THEN THIS IS COLLAPSEING THE HIERARCHICAL CLUSTERING OF BRAIN REGIONS, IT'S JUST EASIER TO SHOW, SO RELI THE DRIVING REALLIES DRIVING SIGNAL WAS IN PREFRONTAL CORTEX -- ALL THESE DISPARATE AUTISM GENES, WE WERE SEEING WHAT LOOKED LIKE ENRICHMENT IN A PARTICULAR PERIOD OF TIME, AND SUBSEQUENTLY WE WE'VE DISCOVERED ADDITIONAL AUTISM GENES AND EACH TIME THAT WE'VE GONE BACK NOW, SEEDING WITH THE HIGHEST CONFIDENCE GENES AND USING THE ADDITIONAL GENES THAT WE'VE IDENTIFIED, THESE PROBABLE ASD GENES, WE CONTINUE TO GET NOISE VARIES, BUT THE SIGNAL COMING UP IN MID FETAL CORTICAL DEVELOPMENT HAS BEEN PARTICULARLY STRONG. AND ACTUALLY I SHOULD SAY THAT FIRST PAPER JEREMY WAS FIRST AUTHOR IN 2013, IN THAT SAME ISSUE WAS A PAPER FROM DAN'S LAB USING A DIFFERENT GENE LIST, A DIFFERENT APPROACH AND DIFFERENT STA CITIES TICS AND FOUND MID FETAL CORTICAL NEURONS. WOULDBOTH OF US FOUND IT WASN'T JUST OVERALL CORTICAL NEURONS BUT THAT THERE WAS A PARTICULAR SIGNAL IN CORTICAL EXCITATORY NEURONS. HE HAD MORE IN UPPER LAYERS, WE HAD MORE IN LOWER LAYERS. THAT SEEMS TO BE RESOLVING AROUND DEEP LAYER GLUTE MATTER JIK -- IN FETAL DEVELOPMENT. I'M LOOKING AT THE TIME, WANT TO MAKE SURE I CAN GET THROUGH THIS. SO WHAT I WANT TO SHOW YOU IS THERE'S A LOT OF EXCITEMENT AROUND WHOLE GENOME SEQUENCING, IT'S A TERRIBLE WAY TO FIND GENES. YOU WANT TO FIND GENES IN AUTISM, USE EXOME SEQUENCING. BECAUSE WHOLE GENOME SEQUENCING INCREASES THE CERT SPACE, THE MUTATIONS HAVE SMALLER EFFECT AND IT'S VERY HARD TO INTERPRET THEM WHEN THEY FALL OUTSIDE OF GENES. SO IT'S EXPENSIVE, BUT AS A GENOME-WIDE APPROACH, YOU NEED A LOT OF POWER. SO WHAT THIS TABLE IS SHOWING, WE'VE GOTTEN TO ABOUT 5,000 FAMILIES, IF YOU HAVE A RIGOROUS STATISTICAL THRESHOLD, WHICH IS THAT BLUE LINE RIGHT THERE, SO FAR WE'RE SEEING SIGNAL THAT'S STARTING TO CREEP IN THAT DIRECTION BUT AS OPPOSED TO BEING ABLE TO SEE IN THE EXOME A DIFFERENCE IN ABOUT 200 FAMILIES RECAPITULATE IN 2000, WE'RE UP NOW -- WE PREDICT THAT WE'RE PROBABLY GOING TO NEED SOMEWHERE AROUND 5,000 FAMILIES TO IDENTIFY JUST THE REGIONS IN THE NON-CODING GENOME THAT MAY BE CARRYING RISK. BUT WE THINK THAT NON-CODING GENOME ACTUALLY CAN BE REALLY HELPFUL IN MOVING AGO THIS PROCESS OF IDENTIFYING SPATIAL AND TEMPORAL DIMENSIONS OF RISK, AND THE REASON WHY IS THAT WE'VE KNOWN FOR QUITE SOME TIME THAT NON-CODING REGIONS, GAVE YOU SORT OF A PICTURE OF LOOKING AT ENHANCERS AND DIFFERENTIAL EXPRESSION OF ENHANCERS IN DIFFERENT TISSUES, THAT A SINGLE REGION OF THE GENOME THAT IS AN ENHANCER ACTUALLY CAN HAVE EXQUISITE REGULATION WITH REGARD TO SPACE AND TIME, RIGHT? SO IF YOU HAVE A DE NOVO MUTATION THAT FALLS IN A GENE, THAT GENE MAY BE EXPRESSED -- OR YOU MAY HAVE A VERY DIFFICULT TIME SORT OF NARROWING IN ON THE WHEN AND WHERE THAT EXPRESSION IS RELEVANT FOR YOUR MUTATION, BUT IF YOU KNOW THAT A GENE IS CARRYING AUTISM RISK AND THIS IS AN EXAMPLE OF THAT, NOW FROM WHOLE GENOME SEQUENCING, IF WE FIND A DE NOVO VARIANT IN AN ENHANCER F WE CAN DEMONSTRATE THAT THAT RECAPITULATES LOSS OF FUNCTION OF THE TARGET GENE, NOW WE CAN USE THE NON-CODING REGION AS SORT OF A ROSETTA STONE, RIGHT? BECAUSE THE MUTATION NOW, IF IT'S LANDING IN A REGION -- THAT'S ONLY RELEVANT FOR AN ENHANCER IN A PARTICULAR CELL TYPE AND PARTICULAR BRAIN REGION, IT ADDS A DIFFERENT WAY OF THINKING ABOUT CAN YOU GET TRACTION ON THIS KIND OF SPATIAL -- OF RISK. WE'VE REALLY BEEN TRYING TO MOVE FORWARD, THIS ACTUALLY STARTED IN MY LAB WITH ANTONIO, ALLAN HOFFMAN, CHILD PSYCHIATRIST, NOW MOVING THIS FORWARD AT YALE ACTUALLY WITH ANTONIO, AND I JUST REALLY WA.KED WANTED TO PUT THIS UP HERE BECAUSE I THINK ONE OF THE THINGS THAT IS VERY IMPORTANT IN GOING FROM MUTATION TO BIOLOGY AND HOPEFULLY PATHOPHYSIOLOGY IN ASD IS THAT THIS NOTION OF CONVERGENCE, I THINK IS GOING TO BE REALLY CENTRAL, THAT PULLING ON THE THREAD FOR A SINGLE GENE, THERE'S SO MUCH BIOLOGY THERE THAT WITHOUT BEING ABLE TO KIND OF TRIANGULATE ON WHAT'S RELEVANT FOR OTHER GENES IN AUTISM, YOU'RE GOING TO BE IN TROUBLE. SO HERE IF THINGS LIKE ZEBRAFISH, ORGANOIDS, STEM CELLS, THINGS THAT ALLOW YOU TO TAKE MULTIPLE DISPARATE AUTISM MUTATIONS AND MODEL THEM SIEM FEIGN TAIN SIMULTANEOUSLY ARE GOING TO BE PRIT KRITICALLY IMPORTANT IN WHERE WE'RE HEADED. I DO WANT TO JUST REAFFIRM THAT WHILE THEY CARRY LARGE RISKS, THE MUTATIONS NOT ONLY A HANDFUL OF SITUATIONS LEAD TO NOTHING, THE ONES THAT WE'VE IDENTIFIED, BUT THAT THERE'S THIS VERY BROAD NEURAL DEVELOP MEN DEVELOPMENTAL OUT COME. S. WE DO THINK THEY CAN BEGIN TO CONSTRAIN EXPERIMENTS, AT LEAST WHERE CAN YOU BEGIN TO SAY IF I'M GOING TO MODEL THIS IN SOMETHING, THERE'S A PARTICULAR TIME IN PLACE THAT AT LEAST I HAVE A HYPOTHESIS THAT THAT MAY BE THE BIOLOGY THAT'S MORE RELEVANT TO BUY OL THAT I MIGHT NOT SEE IN NON-CONVERGENT SPACES, AND DWOA THINK THEY PROVIDE NOVEL AVENUES, DIFFERENT THAT'S BHA'S GOING ON RIGHT NOW WITH DEPRESSION, SCHIZOPHRENIA, ET CETERA, WHERE THE CHALLENGES AROUND COMMONATORIAL SMALL EFFECT VARIANTS ARE REALLY FRONT OF MINDS, FOR US IT'S QUITE DIFFERENT, WE HAVE VERY LARGE MUTATIONS CARRY DIFFERENT RISKS, BUT I HOPE I'VE CONVINCED YOU THAT ONE SIZE DOES NOT FIT ALL. SO THANKS VERY MUCH FOR YOUR ATTENTION, AND I'VE ALREADY HIT ON THE FOLKS WHO CONTRIBUTED MOST CONCRETELY TO THE FINDINGS BUT AS YOU HEARD IN THE INTRODUCTION, THIS IS REALLY ACTUALLY JUST A SMALL PIECE, IT'S A CAST OF THOUSANDS, AND WITHOUT OUR CLINICAL COLLABORATORS BOTH IN AUTISM AND TOURETTE'S, I WOULD HAVE A BLANK SLIDE DECK. THANK YOU VERY MUCH FOR YOUR ATTENTION. [APPLAUSE] I'M SORRY, I RAN LONG ENOUGH THAT I KNOW YOU'RE GOING TO HAVE TO LEAVE, BUT IF THERE'S TIME FOR -- I'M HAPPY TO STAY AND I CAN HANG AROUND AND ASK QUESTIONS AS WELL. DO WE HAVE TIME FOR ONE QUESTION OR SHOULD PEOPLE JUST GO? >> SO IF IT DIFFICULT TO GO FROM GENOTYPE TO PHENOTYPE AND YOUR GENES ARE LOCATED MID FETAL DEVELOPMENT, HOW DO YOU [INAUDIBLE] >> WON'T THAT BE THE BEST -- >> SO IT'S A GREAT QUESTION SO WE MAY BE TALKING ABOUT PHENOTYPE IN A SLIGHTLY DIFFERENT WAY, SO WHEN I'M TALKING ABOUT PHENOTYPE, I'M TALKING ABOUT THE SORT OF STANDARD, WHAT IS THE BEHAVIORAL CHARACTERISTICS OF THIS PATIENT IF THEY CARRY THAT MUTATION. BECAUSE THAT'S GENERALLY WHAT WE DO WITH HUMANS IN THE PSYCHIATRIC CLINIC. THERE THE ONLY POINT I WAS MAKING IS THAT ANY ASSOCIATION BETWEEN QUOTE-UNQUOTE BEHAVIORAL PHENOTYPES OR THE OVERALL DIAGNOSIS IS QUITE HARD. THERE ARE SOME GENERAL THINGS THAT WE KNOW, THESE DON'T -- YOU CAN HAVE THE SAME MUTATION AND HAVE A HIGH IQ AND NOT A LOT OF SOCIAL DISABILITY OR YOU COULD HAVE THE SAME MUTATION AND HAVE INTELLECTUAL DISABILITY. IT HAS A TENDENCY TO SHIFT THE ENTIRE DISTRIBUTION BUT IN ANY INDIVIDUAL, IT'S QUITE BROAD. I THINK THE DEEPER QUESTION I THINK YOU'RE ASKING IS SORT OF HOW DO WE UNDERSTAND WHAT ARE THE FUNCTIONAL -- CRITICAL FUNCTIONAL CONSEQUENCES OF SOMETHING THAT'S HAPPENING IN MID FETAL DEVELOPMENT, SO THAT'S MORE WHAT I CARE ABOUT, WHICH IS SORT OF THE FUNCTIONAL PHENOTYPING, CELLULAR CIRCUIT LEVEL PHENOTYPING, AND THERE'S NO QUESTION IT'S A CHALLENGE, I THINK IT'S IN MY VIEW THERE ARE A COUPLE ANSWERS TO THAT. THE FIRST IS THAT YOU'RE GOING TO NEED TO SCAFFOLD MULTIPLE MODEL SYSTEMS, SOME WHERE YOU'LL BE ABLE TO GET TRACTION BUT OTHERS WHERE YOU DON'T, YOU MAY BE ABLE TO DEVELOP HYPOTHESES IN SIMPLER SYSTEMS THAT MAY NOT EXACTLY RECAPITULATE THE DEVELOPMENTAL PROCESS, AND THEN SORT OF TRIANGULATE ACROSS SYSTEMS, SO WE MAY BE ABLE TO FIND IMPORTANT HYPOTHESES FROM ZEBRAFISH THAT THEN WOULD -- ABOUT WHERE SOME POINT OF CONVERGENCE MIGHT BE AND THEN SAY OKAY, THIS IS VALUABLE ENOUGH TO BEGIN TO TAKE A LOOK IN MARMOSET OR EVEN NON-HUMAN PRIMATE TO BEGIN TO ANSWER THE QUESTION. THE SECOND THING IS I WANT TO MAKE CLEAR THAT JUST BECAUSE WE HAVE A SENSE THAT THERE'S A CONVERGENCE IN MID FETAL DEVELOPMENT, WE DON'T HAVE A SENSE THAT WHATEVER IS HAPPENING DEVELOPMENT. IT LOOKS LIKE THERE'S SOMETHING CRITICAL THERE, BUT YOU KNOW ONE OF THE THINGS THAT WE KNOW FOR SURE IS THAT WHILE WE'RE NOT GREAT AT IT, EARLY INTERVENTION ACTUALLY CAN REALLY MODIFY COURSE, RIGHT? SO IT MEANS THAT WHATEVER IS HAPPENING, THERE IS SOME DEVELOPMENTAL COMPONENT BUT ALSO AN ONGOING FUNCTIONAL COMPONENT. SO WHILE I THINK IT'S GOING TO BE TREMENDOUSLY IMPORTANT TO BEGIN TO GET SOME TRACTION ON WHAT BEGINS TO HAPPEN, THERE IT'S REALLY NOT AS IMPORTANT AS UNDERSTANDING WHAT ARE THE LONGITUDINAL SEQUELAE. ALTHOUGH I DO THINK BEGINNING TO FIND A POINT OF CONVERGENCE CAN HELP US BEGIN TO DIFFERENTIATE SORT OF LATER IN TIME WHAT MIGHT BE PRIMARY AND WHAT MIGHT BE SECONDARY, THE SORT OF CAUSE AND EFFECT CHALLENGE THAT I DESCRIBED AT THE BEGINNING OF THE TALK. YES. >> [INAUDIBLE] >> YES. SO THE QUESTION, IS THIS REALLY ONE ALLELE OR MAYBE THERE'S A SECOND EVENT OR BACKGROUND. SO WE'VE LOOKED FOR SECOND EVENTS, EITHER SECOND DE NOVO MUTATION OR SPECIFIC OTHER GENETIC RISKS ARE COMBINING, WHAT WE THINK WE'RE SEEING IS -- SHOCKING THAT -- EFFICIENCY, WE'RE ALREADY UP TO LIKE A HUNDRED GENES THAT ARE IMPORTANT AND THE DOGMA, WHEN WE STARTED THIS, WAS, YOU KNOW, IT'S GOING TO BE DOMINANT NEGATIVE IF ANYTHING, AND THERE ARE GOING TO BE A VERY SMALL NULL NUMBER OF MUTATIONS. >> [INAUDIBLE] >> THERE YOU GO. SO SMA AND OTHER THINGS LATELY HAVE SUGGESTED THAT, YOU KNOW, THAT MIGHT NOT BE A BAD THING, BUT WE REALLY DON'T UNDERSTAND IT. AND I THINK IT PRESENTS OTHER CHALLENGES FOR MODELING, THAT THE QUESTION IS A KNOCKOUT JUST MORE OF THE SAME OR DO WE REALLY NEED TO STUDY HEAD HEATHER ROW SIGH GOSS IT TO UNDERSTAND WHAT THE BIOLOGY IS. YES? >> [INAUDIBLE] >> THE QUESTION IS WHAT ARE THE RISK FACTORS IN PARENTS THAT MAY LEAD TO DE NOVO MUTATION, AND THE ANSWER IS THE MAJOR RISK FACTOR THAT WE'VE BEEN ABLE TO IDENTIFY IS PATERNAL AGE. AND THERE'S SOME RISK ASSOCIATED WITH MATERNAL AGE BUT THE EFFECT SIZE FOR OLDER FATHERS IS MUCH GREATER. NOW WE NOW HAVE ENOUGH DATA FROM WHOLE GENOME SEQUENCING TO BEGIN TO ASK QUESTIONS ABOUT WHETHER OR NOT IT LOOKS LIKE THERE ARE OTHER EITHER ENVIRONMENTAL FACTORS OR OTHER HERITABLE FACTORS THAT SEEM TO INFLUENCE THE RATE OF DE NOVO MUTATION, AND SO FAR THE VAST MAJORITY OF THE CHANGE IN DE NOVO MUTATION RATE IS ALL ATTRIBUTABLE TO AGE. WE SEE NO EVIDENCE AT ALL FOR AN ENVIRONMENTAL COMPONENT TO THE RATE OF DE NOVO MUTATION. WHOLE GENOME SEQUENCING AND 10,000 PEOPLE. SO INTERESTING FINDING, NOT WHAT WE EXPECTED, BUT THAT'S THE MAJOR THING THAT WE KNOW SO FAR. >> IF [INAUDIBLE] -- WHAT DOES THAT SAY ABOUT TREATMENT? >> QUESTION, WHAT DOES IT SAY ABOUT TREATMENT PROSPECTS. IT'S RELATED TO THE ANSWER I GAVE BEFORE, WHICH IS THAT -- SO WE'RE INTERESTED IN CONSTRAINING EXPERIMENTS TO BEGIN TO UNDERSTAND WHAT WE CAN TRACK GOING FORWARD, THIS IS NOT A HYPOTHESIS THAT -- THIS IS CLASSICALLY DEVELOPMENTAL IN THE SENSE THAT THERE IS A LESION AT THIS POINT WHICH THEN BECOMES FIXED SO THAT IF YOU WERE GOING TO TREAT, YOU HAVE TO TREAT BEFORE THAT CAME ABOUT. AND IN FACT, I THINK THERE ARE MULTIPLE KIND OF DIFFERENT AVENUES OF EVIDENCE THAT SUGGEST THAT NEURODEVELOPMENTAL DISORDERS ARE MUCH MORE PLASTIC THAN WE WOULD HAVE THOUGHT YEARS AGO, SO FOR INSTANCE, I'M SURE EVERYONE HERE IS FAMILIAR WITH SOME OF THE EXPERIMENTS AROUND TOURETTE'S SYNDROME OR FRAGILE X WHERE YOU CAN REVERSE MUTATIONS OR PHARMACOLOGICALLY -- I THINK THERE'S STRONG EVIDENCE THAT THERE ARE ASPECTS OF THOSE DRAININGMENTS THAT ARE NOT SET IN STONE, THAT ARE CONTINUING THROUGHOUT THE LIFESPAN, AND WE ALREADY NO, KNOW, WE HAVE NO IDEA WHAT TO TARGET, WE DON'T KNOW WHAT TARGETS ARE INVOLVED AND USING THE CRUDEST -- WORKING ON LANGUAGE, AND WE CAN STILL HELP THE BRAIN DEVELOP IN A MORE NORMAL WAY IF WE DO THAT. SO WHILE I UNDERSTAND SOME DAYS WHEN I'M NOT FEELING SO OPTIMISTIC, I REVEERT TO THERAPEUTIC NILISM AND SAY A LOT OF THE BADNESS COULD BE VERY EARLY AND THAT COULD BE REALLY TOUGH FOR US, BUT THEN I SEE KIDS IN CLINIC AND REALIZE THE HORSE IS NOT COMPLETELY OUT OF THE BARN AND AT A MINIMUM, WE WOULD BE DOING BET THAN WE'RE DOING NOW IF WE KNEW WHAT THE UNDERLYING CHALLENGES ARE AND WHAT CIRCUITS WE NEEDED TO TARGET AND WHAT THE PATHOLOGY IS. SO I THINK THAT I REMAIN OPTIMISTIC THAT EVEN IF WE CAN'T FIX IT ALL, AND THEN WITH THE STUFF THAT'S GOING ON WITH SPY KNOW MUSCULAR ATROPHY, SOME OF THESE MUTATIONS HAVE HUGE EFFECTS, RIGHT? IF YOU HAD A CHILD WITH A LOSS OF FUNCTION OF CHDA, YOU KNOW, YOU HAVE 50 FOLD INCREASE IN RISK FOR AUTISM, I THINK IF YOU STARTED ADDING THE LIKELIHOOD OF SEVERE INTELLECTUAL DISABILITY OR SEIZURE, IT'S NOT INCONCEIVABLE TO ME AS THINGS LIKE RNA EDITING MIGHT BECOME MORE VIABLE, THERE MAY NOT BE VERY SPECIFIC TREATMENTS FOR VERY HIGHLY PENETRANT EVEN THOUGH THERE -- RAISES A HUGE NUMBER OF ETHICAL QUESTIONS BUT CERTAINLY SOMETHING THE FIELD WILL BE GRAPPLING WITH IN THE NEXT DECADE. >> IT'S A GREAT QUESTION. THE RATE OF MUTATION IS DICTATED BY THE SEQUENCE CONTEXT AND IN FACT WE HAVE TO CONTROL FOR THAT IN THE EXPERIMENT IN ORDER TO LOOK FOR AN EXCESS RATE OF MUTATIONS SO THE TWO THINGS THAT WE NEED TO CONTROL FOR ARE CG CONTENT AND GENE SIZE. BIGGER GENES ARE MORE LIKELY TO GET HIT, HIGHER GC CONTENT ARE MORE LIKELY TO HAVE MUTATIONS. WHEN WE CONTROL FOR THOSE THINGS, WHAT YOU FIND IS THAT IT'S SIMPLY THE PRESENCE SO FAR OF A LOSS OF FUNCTION, AND RIGHT NOW THAT'S A CONSEQUENCE PROBABLY NUMBER ONE OF THE FACT THAT IT MATTERS, BUT THE OTHERS, THAT'S WHAT WE CAN INTERPRET READILY RIGHT NOW, IT'S VERY HARD TO DO AN UNBIASED GENOME-WIDE SCREEN LOOKING FOR ANYTHING EXCEPT PUTATIVE LOSS OF FUNCTION MUTATIONS, BECAUSE WHEN YOU LIKE AT MISSENSE MUTATIONS, KNOWING WHICH ONE OF THEM MIGHT BE GAIN OF FUNCTION, WHAT MIGHT BE A DOMINANT NEGATIVE, WHAT MIGHT BE A HYPOMORPH IS EXTREMELY DIFFICULT. SO ONCE YOU GET TO THE INDIVIDUAL GENE AND KNOW THAT IT'S CARRYING RISK, THEN WE CAN START TO DIG INTO THE ALLELE SPECTRUM MORE DEEPLY AND SEE WHETHER OR NOT THERE ARE SPECIFIC ASPECTS AND PARTICULARLY VULNERABLE REGIONS IN THE GENE. THIS IS REALLY A FIRST CUT, AND IT'S DICTATED BY WHERE WE CAN PUT THE LIGHT, SHEUN IT ON SHINE IT ON THE GENOME. THANKS VERY MUCH. >> THANK YOU VERY MUCH. [APPLAUSE]