A Whole-Child Approach to Autism with guest Dr. Suzanne Goh

In this two-part series, Dr. Suzanne Goh shares her latest insights on autism with Dr. Amy and Teri. As one of the top experts in the field, Dr. Goh brings a wealth of new information on everything from early signs of autism and getting a diagnosis to pattern-seeking behaviors and the gut-brain connection. Tune in to hear more about what your first steps might be if you’re concerned your child has autism, how to support your child’s unique developmental trajectory, why food elimination shouldn’t be your initial attempt to rule out sensitivities or allergies, and the role schools may or may not play in supporting your child or teen. You’ll also hear Dr. Goh explain the five elements of a whole-child approach to care and why parents’ observations and input are so vitally important in the overall process of diagnosing and support your child with autism. If you have a child or teen with autism, you won’t want to miss this two-part series!

ABOUT US: Brainy Moms is a parenting podcast hosted by cognitive psychologist Dr. Amy Moore. Dr. Amy and her rotating co-hosts bring listeners conversations with experts on topics in parenting, child development, education, psychology, mental health, and neuroscience. Listeners leave with tips and helpful advice for helping moms and kids thrive in life, learning, and relationships. This episode is co-hosted with Teri Miller, MS PSY. 

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Transcript

DR. AMY:  Hi, smart moms and dads. Welcome to another episode of the Brainy Moms Podcast, brought to you today by LearningRx cognitive skills training centers. I'm your host, Dr. Amy Moore joined by my co-host, Teri Miller. And Teri and I are excited to welcome and have a two-part conversation with our guest, Dr. Suzanne Goh. Dr. Goh is co-founder and chief medical officer of Cortica, the largest provider of comprehensive health services for autism in the United States. A graduate of Harvard University, Oxford University, and Harvard Medical School, she is former co-director of Columbia University's Developmental Neuropsychiatry Clinic for Autism, where she conducted research on the biological causes of autism and used brain imaging to identify patterns of neural circuitry and brain chemistry. Dr. Goh is a frequent speaker for advocacy organizations and a champion of neurodiversity affirming care. She's here today to talk to us about autism and share insights from her book, “Magnificent Minds, The New Whole Child Approach to Autism.” Welcome Dr. Goh. 

DR. GOH: Thank you so much. Thrilled to be here.

TERI: So glad to have you here and just appreciate the wisdom that you're going to be bringing. And I think our listeners are going to be really excited. This is an important topic. Autism is such a big topic. So that's why we are doing two episodes with you. And I want to start off by asking you to talk about autism in general. What are the signs parents should look for? What behaviors signal that a child might have autism?  

DR. GOH: So, one of the things that I think is really, really helpful for parents to know as they're watching their children grow and develop, especially in the first few years of life, is that there's just there's so much there's such a wide range of development. And so whatever you're seeing in your own child, first, I would say, pause, take a deep breath. Don't panic, don't worry. There's so much that your child will reveal to you and so much to learn over time and really the goal is simply to understand, as best you can, you know, the different features your child has, what their strengths are, where there, there might be some areas of challenge. And then secondarily to say, “Okay, does this pattern or what I'm seeing fit a particular diagnosis so that my child can get a further evaluation so that we then know how to best support their unique developmental trajectory?” So I think first the message is one that's really, really positive and hopeful that no matter what you're seeing in your child, there's a way forward where you can provide the support that will help them to flourish. You know, I've worked with so many children and families, at this point in time, I think there's just so much more reason to be optimistic and hopeful than to be fearful or, you know, pessimistic. So, with that kind of more positive, hopeful approach, then I think the next step is to understand the different major domains of child development. So for example, children develop in their sensory systems. They develop in terms of the way they're taking in the world around them through their vision, through their hearing, through their touch. For example, they also develop through their motor systems, how they're moving in the world. So we know there are gross motor skills where children learn to roll and then they learn to sit and crawl and walk. And so there are motor milestones. And then there are what we call social or emotional milestones. So, what we're looking for in children is how they're engaging with other people, whether it's looking, whether it's looking, communicating through sound and vocalizations, eventually play and interacting and then conversation. You know, so there are all these kinds of major areas of child development that you want to be, have in mind as you're watching and observing your own child. And autism, which we know now has gotten a lot of attention. We know that rates are increasing and autism really refers to when a child's development in their social skills and their communication skills is delayed. So what might that look like? So, we know that there are some very early signs, that even as early as 9, 12, 18 months, some of the common early signs may be a child who's not making eye contact. So if you're trying to engage with your child, but they're not looking in your eyes. Another early sign is delay in the development of spoken language. So most children will babble around the age of nine months, meaning they're making consonant sounds like baba, dada. And then around a year old, most children will have one word. By 15 months, most children have about 10 to 15 words. So those are some of the milestones we're looking for. And delays in spoken language are also one of the early signs of autism. One set of characteristics that has long been overlooked but now we understand much better our differences in sensory processing. And sometimes in infants, even less than one year of age, early signs of autism might look like very high level of irritability, you know, so children who are, who are very hard to console. But on the flip side, it might look like children who are very, very easy babies.  And so sometimes parents say, “Well, how could this be?” It's because children can have sensory—hat we call hypersensitivities, meaning what they're hearing and seeing and feeling from the environment is overwhelming to them. So they'll tend to be a little bit more irritable and harder to console. And then there can be sensory hyposensitivities. So some infants are less … the center stimuli affect them less. So they seem to be easier babies and they're less fussy and they make less noise and they demand less of their caregivers. So those are some of the early signs that can be indicators that might lead us to want to evaluate further.  

DR. AMY: Can you speak to what we might see in preschool and early elementary? Like, let's say, you know, those flags from early childhood didn't show up or we didn't notice them as much, what might be red flags then as kids become four, five, six, seven.

DR. GOH: So, children in preschool years or early school age can show a range of differences that might point to autism. And those differences fall into two main categories. One relates to what we as healthcare professionals think of as differences in social interaction and communication. And the other category and I'll talk more about each of these but the other category is referred to as restricted or repetitive behaviors or interests. So in that first category, the differences in socialization and communication, it can look like children who interact less with peers. They don't initiate social interactions as much and they don't respond to other children as much for looking to interact with them socially. Delays in spoken language. So more difficulty with speech or reduced speech is another sign. And some children will prefer to sort of be on their own. And when they play on their own, their play tends to be a little bit more repetitive. So, for example, instead of playing with toys, sort of as they're intended, making stories, they might, for example, prefer to spin the wheels on a toy car or push a particular button, you know, on a toy. So that type of more repetitive or restricted type of play is also an early sign. Some children in their sort of school age years also really like to explore things in a sensory way. So for example, being at a playground, they might play with their hands in the sand rather than running and playing with other children and, you know, engaging those kinds of ways. 

DR. AMY: So you, you talked in your book about that pattern-seeking behavior that when we see those repetitive behaviors, there's something really fascinating going on in the autistic brain. Talk a little bit about that. 

DR. GOH: Yeah. So, we, you know, if children are engaging in repetitive ways, you know, with toys or objects or parts of their environment, why? You know, so important always to ask why. And the more we learn about autism, the more we realize that a lot of those repetitive behaviors represent a child's unique way of exploring their environment, seeking to understand it, looking for patterns. You know, like, “If I turn this light switch on, does the light turn on? Does it do that every time? If I open and close this door, what changes? What are the mechanisms that allow for this door to open and close?” So there really is like this curiosity and seeking to understand the world around them. Even a child who's exploring, for example, sand, the feeling, the texture of sand, that too indicates a curiosity and a desire to understand. So I think it's important not to paint these behaviors in a negative light, but really to understand them and to understand why a child might be engaging in them.  

DR. AMY: Yeah. You even said these, these kids can become inventors when allowed to explore their environment and the patterns like that.

DR. GOH: Yes, that's right. And there's this idea of having a pattern-seeking mind, or the other word that's sometimes used is systematizing. So seeking to understand systems in the world, how things work, that is the basis for invention. And Simon Baron-Cohen is a psychologist who's written a lot about this idea. And that, yeah, I just think it's so important that we appreciate it and recognize it.  

TERI: So I'm really curious. I keep wanting to insert. I'm so curious about kids that display in a really different way. And I'm going to use a personal example, as I often do. Listeners, you know, I have nine kids. I've got lots of examples right here for so many different things we're learning out, learning about. 

DR. AMY: We like to say that Teri has a psychology lab. 

TERI: Yeah, even, even before I had my masters, I called myself a child development researcher because that's just life as a mom of nine kids. Okay, so here's, here's the question. So what about kids that display really different than what you're describing. And here's the example: kids that are very, very high-functioning autism. And so I've got a kiddo, he's actually 18 now. He spoke very early. He talked very, he walked very early. And when I say spoke early, I'm talking like complete sentences, complete thoughts. We have a, you know, a funny story. We, talked about in the grocery store one time. He potty trained early, just had this like old soul insight. And we're talking before he was two years old. So not just a little bit, but very sort of advanced for his age. Very thoughtful, deep thinking, like sort of like you’re talking about, kind of the systems. But he did play very well with his siblings. There was never any indicator that there was a problem. My thought was just, “Wow! I’ve got this little genius kiddo!” And then as he began to be in school and move forward with interactions with his peers and social environments, it became very clear that he was extremely overstimulated by a classroom environment. He did not do well with peers. If he had one or two friends that we had really, really cultivated in our home and he became very comfortable with, he built friendships. But it took a very long time. He does. He looks in the eye. So we, especially when it was younger, he is, he is withdrawn socially, you know, very much and cautious.  But we now, as he's a young man and a teenager. It's come up like, “Oh my gosh!” He has he's been like, “I don't fit in.” And he's, he's really sort of been traumatized by his differences and the social anxiety. And so now it's been like, “My goodness, I think he is on the spectrum. And now where do we go? How do we help him understand himself a little bit better?” So speak to that scenario for parents. 

DR. GOH: Yeah. Yeah. So, I think one of the mistakes that we make is that we kind of impose on children an idea that everyone should interact socially in a particular way. So now we refer to that kind of set of expectations as “neurotypical social standards” or “social practices.” And we just have to realize that those aren't right for everyone. So, but at the same time, all people desire some level of social connection. And so how do we help a child connect with others socially in the way that suits them?  And so in, in what you've just described, Teri, I think it's helping to replace this idea of there's something wrong with me. I don't fit in. I must have some kind of deficit or something, you know. With this other set of ideas of, “Okay, you don't have to fit that mold and let's find what does fit for you.” I think if we can take away that layer of “I'm supposed to be. X,” you know, “I'm supposed to, my social life is supposed to look like this,” then I think then that's when we can really start understanding what does work, you know. And depression, anxiety, you know, all of these mental health difficulties, I think they're a consequence of us thinking, we call them the shoulds. You know, this whole, the set of expectations and then once depression and anxiety set in, then, you know, there are a whole host of obstacles, right? That makes things so much, so much harder.  

TERI: Does that, does that descriptor fit high-functioning autism? That you can have kiddos … because I've read about it, that there are kiddos that are really, really early talkers and they have this deep introspection and yeah, they're, they're very fixated on, you know, certain sort of high-level topics before you think they would be. Is that, is that a descriptor?

DR. GOH: Yes, it is. And so what you described is very much within what we now consider to be the autism spectrum.  And you know, there are adults, male and female, now who are increasingly seeing that their characteristics, what they experienced throughout childhood and adolescence, and even adulthood really does fit what we now understand as, you know, part of the autism spectrum. And I think it's helped, you know, sometimes I'm asked, well, “What should I then pursue a diagnosis, you know, so many years have passed?” You know, I think it's, it's very individual. Would that process of evaluation and ultimately diagnosis help that individual to understand themselves better to then draw on more supports, have more tools … 

DR. GOH: So the decision of whether to pursue a diagnosis, especially for, you know, an adolescent or an adult who, you know, we might call my fifth kind of the profile of what we used to be called Asperger's. I think whether or not you pursue a diagnosis really is a very individual decision about whether it will help you in the way you think about yourself, how you think about your identity, access more supports, and if it will help you to have more tools that will serve you well. 

DR. AMY: Yeah. So I think that we're seeing a lot of this curiosity in older adolescents and adulthood about whether our behaviors are consistent with the autism spectrum, right? And, and I'll be vulnerable here and just share that I am an ADHD warrior. And so, I recently had a conversation with my therapist and said, “I think I'm on the spectrum too.” Right? And we, so we spent some time looking at, you know, my, you know, lack of social awareness, right. Is this consistent with the autism spectrum? And so, you know, where we landed was there's a lot of overlap between ADHD and autism. And so, that's frequently, co-morbid, co-occurring, right? So I would love for you to speak a little bit to the differences in ADHD and autism, where they overlap and should we try to tease those apart? Is that important?  

DR. GOH: Well, these are all diagnostic constructs, meaning, you know, autism, ADHD, anxiety, OCD, sensory processing, all of these are categories or, you know, labels in a sense that we have developed to try to describe the experiences that people have. And so they do overlap a tremendous amount. And none of these points to particular biological cause. So for, you know, underlying this is a lot of biological complexity. But the way that I think about autism is that it's primarily, it's when somebody's experiences and their characteristics have more to do with difficulties with socialization and communication and a tendency towards more limited or repetitive types of behaviors and interests, where that is the most prominent feature. ADHD to describe individuals who have more, the prominent parts of their experience relate more to difficulty with focus, concentration, attention, and for some impulsivity and hyperactivity. There's a lot of overlap. There's, you know, an estimated, you know, 30 percent or more of autistic individuals also fit the diagnostic criteria for ADHD. So I think it's important, really, to think about how an individual wants to, how, what they consider, you know, to be their own experiences and identity and to go from there. And it does, part of why understanding if the diagnosis of autism or ADHD is more appropriate, is that it does kind of take you in different directions in terms of treatments that you might want to try first. Ultimately you can try, you know, you're not limited in what you try, but initially it can help to have a diagnosis to guide you. 

TERI: Hey, you just perfectly segued into what I would like to talk about next. We could not have scripted that more beautifully.  

DR. AMY: That's amazing!  

TERI: Because I want to talk about, as our listeners, as a parent, we get our kiddo diagnosed, we get some more information. Then where do we go from here with our schools, with services? What's the next step? 

DR. AMY: Well, what's the first step? 

TERI: There you go. First step. Yeah. The diagnosis. 

DR. GOH: Yes. So, I get this question a lot actually of who is best, who should you go to to get a diagnosis. And you actually, you do have a lot of options. You know, I think, for the most part, psychologists in our communities and in, you know, children's hospitals and medical centers are really the specialists whose focus is on making these types of diagnoses in children. But there are, in part because these diagnoses are much more common, there are a lot of other options too. So a more, a medical route would be to have an evaluation with a pediatric neurologist or child psychiatrist. Many general pediatricians even today are very skilled at making these diagnoses. So, you know, I tell parents there are lots of options. When you go the route of having an evaluation with a psychologist, you very often will then follow that up with a medical evaluation. So that path is perfectly fine. If you start with a physician like a pediatrician or pediatric neurologist, they could then guide you to say, “Oh, for your child, I think a more in-depth psychological evaluation would be helpful.” So regardless of which path you go on, it's very likely, you know, you'll be along that path you'll get the touch points that you need for, you know, for the clarity that you're seeking. So that's the diagnostic process. What comes out of the diagnostic process will be a set of recommendations related to therapies like, for example, behavior therapy, you know, for autism, occupational therapy, which is more focused on, you know, things like sensory processing skills, fine motor skills, daily living skills for some children, physical therapy, which is a little more focused on gross motor and some fine motor skills. Speech language therapy, just very much focused on speech, language and communication. So there's that set of recommendations and there should also be a set of medical recommendations. You know, so given your child's profile is additional testing, medical testing needed, like. genetic testing, metabolic testing, maybe a brain scan, maybe an EEG. You know, so it's important that both of those components are addressed, you know, as part of the diagnostic evaluation and the segue into the treatment.

DR. AMY: Yeah, because you said that one in eight kids with autism have epilepsy. 

DR. GOH: That's right. 

DR. AMY: So that's important to evaluate to see.

DR. GOH: Yes, absolutely. Because often, because epilepsy is very common and often you don't see outward signs. So a child might be having seizures and you may not see any signs of it. You won't see the shaking, the losing consciousness. You won't have those kinds of episodes. The only sign you'll have may be a developmental delay or disruptions to behavior and cognition. So, evaluation procedures are essential. Even for those with ADHD, epilepsy is not as common among those with ADHD, but, um, atypical electrical discharges on an EEG and electroencephalogram is present in about 25%. And if you find that on EEG, it then could guide the decisions you make around potentially medications, you know, and other interventions. 

TERI: I think it's great also what you, I'd love that you just brought up the connection with epilepsy, because it also is something for listeners to understand can come the other direction. If you've got a kiddo that has a seizure disorder that has epilepsy, and that was my case with my oldest. He had epilepsy and the ADHD, sorry, the autism diagnosis, came later. And so there was, you spend so much time if your kid has epilepsy, focusing on that medical issue of controlling the seizures. And so it seems like the behaviors and the struggles are a manifestation of epilepsy and it can just be co-occurring. And so then, yeah, it's never too late to then even help your teenage child, your young adult kiddo that's, you know, an adult now that's had epilepsy to look at, “Hey, let's, let's get this diagnosis so that you can better understand yourself and know how you can function in the workplace.”

DR. GOH: That's right. I think it's so important, and it's just important not to neglect, you know, one or the other. So yes, we can seek to understand a lot more biologically medically provide those supports and treatments. And then we also want to be thinking more in terms of development and behavior and mental health and be able to address, you know, all of that. And I know it can be, that can seem overwhelming, but you can take it one step at a time. 

DR. AMY: So I want to, I want to speak a little bit more about that development and you encourage parents to get away from the “I don't know” mentality and start with what they do know. And so when you're looking at your child and you're looking at all of these domains of development that you that you spoke about, should parents be looking for delays in multiple domains as a red flag or can a delay in just one of those domains signal, “Hey, maybe we need an evaluation for autism”?

DR. GOH: Yes, I would say a delay in a single domain should be a signal to get further evaluation and also should be a signal to then look more deeply at the other domains. Because they're a child who does have a delay in one area, it would really, if there are delays in others, it really does influence then how you want to, your approach and the supports you want to provide and very likely the testing that you want to do. 

DR. AMY: And you're, and as a parent, you're the best person to say, I mean, you're seeing your child all day, every day, right? And so you're able to say, I know this about my child and I know my child is not doing this. So instead of feeling like you're, you are unaware and you are helpless, you're full of information about your child, right? 

DR. GOH: That's right. And I think it's so important that parents don't discount their own knowledge. You know, they should really recognize the value of what they know and also not allow professionals assessments to replace their own understanding of their child. They really should be viewed as equally important and one will inform the other. And yes, professionals views and evaluations and findings are important, but they should never replace what a parent understands and knows and believes about their own child. 

TERI: So when is a, when is a kiddo too young or when is the right age? So it's interestingly, I spoke about my son that's 18, who was super, super advanced. It never occurred to me until he was, you know, a teenager, maybe middle school, that this is something we could look at. And then my oldest son, who's, you know, almost 29 and his struggles started out with epilepsy, a medical issue. And now I have my grandson, he's three and his speech delays are very significant. He didn't babble a lot. He does struggle with connection or attachment, that social connection. And then he, at this age, he can say very, very few words. And so he's had some, he's already getting some early intervention through like a preschool program. But is three, is that too young, is now a good time to get him that evaluation so that he can get support for possible autism?  

DR. GOH: Well, this has been one really positive development in our field is that our ability to diagnose accurately at a younger age has really improved. So for autism itself, really at this point, between ages 18 to 24 months, most professionals feel quite confident in making a diagnosis. They might just monitor the child for a while and wait until maybe age two and a half or three years to formally make the diagnosis. But really, I think I would say many of us professionals will want to see a child as young as 18 months. 

TERI: Wow. 

DR. GOH: Even at that age, the diagnosis can be made very accurately. Now I would even go a step further and say, as a pediatric neurologist, I would want to see the child at age six, nine or 12 months even. Because even though the sort of language and maybe social milestones aren't yet there to allow for an autism diagnosis, I'm looking at sensory processing, I'm looking at fine motor skills. And some of those early signs. Not so that I can make an autism diagnosis, but so that I can then coach the parents and how they might engage the child to support their development, even from, you know, such a young age, or maybe occupational therapy, you know, might be appropriate to help with the development of some of those sensory and motor skills. 

DR. AMY: Do you think that the school systems are equipped to handle all of the interventions, or do you recommend that parents seek interventions outside of the school system? 

DR. GOH: That's a great question. So school systems vary so much in terms of their knowledge, expertise, and resources. And so I'll say that it's not likely that your school system will be able to provide everything that you as a parent will want for your child. And so that means, yes, exploring resources through the school system, becoming knowledgeable, talking to other parents. Some school systems are fantastic, but it's very likely you'll want to supplement that with, for example, clinic-based therapies or maybe in-home therapies. So yeah, you can't rely, unfortunately, you can't rely on the school system to do it all. 

DR. AMY: Does insurance cover a lot of the community-based therapies for autism? 

DR. GOH: Yes, very, very often, and that's improved over time. So, you know, 10, 20 years ago it wasn't the case, but now insurance coverage is much, much better. There are also often state-provided resources. So for example, in California, there's, we have something called the regional center system, which provides early intervention for children, you know, under three years of age to access very high quality occupational therapy, speech language therapy, and other early intervention services. Many states have similar programs. So, either insurance-covered or state-provided services are available very early on.  

TERI: And so that diagnosis, what I've learned, and so speak to this, the diagnosis can help make those interventions available. For example, I mean, throughout the lifespan. For example, say with my grandson, if I were able to help get him evaluated, and he ultimately ended up with that autism diagnosis, then he would qualify for like state waivers, even some federal funding that would provide professionals that could even come to his home that could help him out there, that could then follow him through the, through the lifetime. So even for my older son, if he ends up with that autism diagnosis, he could get help for managing work situations and job training. Talk about those. 

DR. GOH: Yeah, such an important point because I think, one of the most important things I feel for parents who know is that today an autism diagnosis opens more doors than it closes. It accesses more supports. And I think parents are sometimes fearful that a diagnosis will somehow, you know, be a night, close things off, reduce the possibilities for their child. And now it's actually the opposite. So we're very fortunate, because I think in the past, a few decades ago, that was not the case and autism diagnosis might have harmed, you know, place a label and restricted a child's opportunities. But today it's not the case. And I think we're fortunate that there's been such expansion of our understanding of autism. And so people now recognize that it doesn't limit a child's potential and abilities, but it does help us to support them better.  

TERI: Yes. That's so important. Yes. Yes.  

DR. AMY: So, for a parent who is trying to process a new diagnosis, right, they're, they have found out that their child has autism, what support systems are out there? Do you have a, I know there are multiple autism, I mean, I'm sorry, there are multiple autism organizations, um, that provide support groups and conferences. What organizations do you recommend to your families for support?

DR. GOH: There are so many. And again, that's a real positive. So there are organizations, advocacy organizations that support parents, caregivers. There are also autism advocacy organizations led by autistic individuals themselves that support autistic individuals. We actually try to provide as much information as possible so that the parents can pick because you really, each organization has its own personality and its own take on things and its own priorities. And so we just wanted to match the parents’ priorities and their values. So we don't, at CORTICA, we don't align specifically with a particular advocacy organization. We try to provide information for as many as possible so that parents can pick. But there are just, so parents are aware, there are some that really prioritize medical treatment and medical management. Those organizations have conferences and they have a lot of physicians and professionals speaking. That's fine. I sometimes find those to be a little bit confusing for parents because the level of information is so detailed and it's something you really do kind of need a guide. So if you're attending those kinds of conferences and part of those organizations, that's great. But you do want a doctor, I think, who can then be your personalized partner to help you make sense of it.

DR. AMY: Okay, so we need to take a break and let Teri read a success story from our sponsor. And when we come back, we'd like for you to talk a little bit about your holistic approach. Just, we're going to spend the second episode with you really drilling down on all of those areas, particularly those that you focus on in your book. But I just want an overview of those. Let's give our listeners an overview of what to expect in our next episode, when we come back.  

TERI: Throughout her life, Aubrey's doctors had told her that she had cognitive issues, which affected her academic performance, confidence, and socialization. “We spent so many evenings at the kitchen table with her crying and her friends out playing and her not being able to, because she had so much homework.” From her mom. Her mom enrolled Aubrey in LearningRx, an intervention designed to target and strengthen cognitive skills. Soon, Aubrey was no longer bringing homework home because she'd completed it at school. Her test anxiety practically went away and her mom says that now Aubrey is thriving. “I now feel like I have a place,” says the teen. “I always had one, I just couldn't find it until LearningRx.” While your child may or may not achieve these same results, LearningRx would be happy to work with you to get answers about your child's struggles with learning. Get started at LearningRx.com or head to our show notes for links to more helpful resources. 

DR. AMY: And we are talking to Dr. Suzanne Goh about autism. So Dr. Goh, You have a whole child approach to care and that's the framework for your new book. And so I would love for you to just talk about those five elements that go into that whole child approach.

DR. GOH: Yeah. So, in my view, a whole-child approach means, well, I also will sometimes call it a holistic approach. It means that you're stepping back and looking at the big picture. And I sometimes use the term whole child path, because I think it very much is a path you've got, You've got time you're going to go on a journey, which can be a lot of learning that takes place, but you want to have your eye on five different areas. So, the first I call brain and body health. So, we know that the head is connected to the body. So, the way the brain develops. and the way the brain functions is so dependent on the health of the entire body.  And so there's a lot, of course, that we want to understand and the last steps we can take to support brain and body health. We're also thinking about, then in more depth brain development. So the kind of second main areas I call development. And those six domains are Sensory motor, cognitive language, social and emotional. So having an understanding of what those are and be able to support a child in each of those areas and help them to develop the brain networks for all of those skills. Behavior is the next big area. And it relates to how we can support a child's behavior through making changes to the environment. There's so much that we can do to support children's development, and their behavior by changing their surroundings, both the people, the way the people interact with them, and also the physical, you know, the more physical aspects of the environment. And then family. So, you know, every child exists in that, you know, context of their family and their home. And there's so many things we can do to support the well-being of family members and to support the safety and the sense of comfort in the home. That's important for child. And then finally, community. So children are having really important experiences in the community in schools, and there's a lot that we can do to shape those. And children grow up and very often look back on some of those community experiences as being the most positive of their life. And it could be things like recreation opportunities, sports, music. And so we don't want to neglect those. So the whole child path involves attention and effort in each of those five areas.  

DR. AMY: I'm really excited to dig into all of those in our next episode, but I would love to talk a little bit about the brain body connection in the time that we have left, particularly the gut brain connection, and why that's important to look at an autism. 

TERI: I love it. Yeah. I love that. You said the brain is connected to the body. And that's immediately where I went that I'm like, Hey, brain gut, it's connected. 

DR. GOH: Yeah. Well, you may have heard the term, the gut-brain axis. So that term is used a lot now to refer to all of the intricate ways that the brain and the gut are connected. So one of the ways is directly by nerves. So there are nerves that run directly from the brain to the gut. The gut has its own sort of mini brain sometimes called the second brain, the enteric nervous system, which is intricate and elaborate very much the way the brain is. And another way that the gut and brain are connected is through hormones, you know, through these chemicals. And many people have heard of the neurotransmitter serotonin and that most of the body serotonin is actually made in the gut. You know, so there are just so many different ways that the gut and brain influence each other. We also know so much more now about the gut microbiome or the microbiota. So the microbes that inhabit the gut. And there's been research showing that there's strong link between a person's microbiome, the composition of the microbiome, and mental health. So that a person microbiome affects symptoms like anxiety and depression. For autism, the research has been really interesting and there's still a lot more research to be done, but so far the research suggests that there are a few different possibilities. So one is that it may be that the features of autism can influence gut health, because we know part of autism might limit the food that a person eats. That in turn can influence the health of the gut. We know that symptoms like constipation and diarrhea, even inflammatory states of the stomach and the intestines, the esophagus are more common in autism. We also know that sensitivity to gluten, or even an allergy to gluten, celiac disease, is more common in autism. And then there's some research showing that if you influence the gut microbiome in certain ways that you can actually reduce some of the features of autism. So very fascinating. And now there's a little bit of, you know, debate currently over what I call like sort of the chicken and the egg, you know, what comes first? Is it that there's disruption to the gut? that then contributes to autism symptoms? Or is it that the features of autism influence behavior and feeding and other things in a way that then includes gut health? And I think for me, I believe the answer is that it's different for different people. So part of my job as a doctor is to try to understand for this particular child, what do I think is the role of gut health for them and then to support it as much as I can.  

DR. AMY: Yeah. So have you kind of developed some nutrition recommendations for your patients that you could share some tips?

DR. GOH: Yes. In fact, you know, the nutrition, gut health, feeding component of autism is so important. We have a full program at Cortica. We have our own nutrition and feeding program that involves both optimizing, understanding a child's nutritional status and their biology and then guiding them in dietary interventions, but then also a whole feeding program where we help them to be able to acquire the skills, the sensory and the motor skills needed to eat, to be able to eat the kinds of foods that will help them. So, in terms of diet, you know, so many families with a child with autism are trying different dietary interventions. And very often they start off by eliminating something from the diet. That is tricky. In my view, that has a lot of risks associated with it because children often already have a somewhat limited or restricted diet. Many children come in only eating 20 or 30 different foods. You know, most days they're eating the same foods over and over. And so if you're already limited and you remove foods, you really do risk certain nutrient deficiencies. And we know nutrient deficiencies are more common in autism. Iron, vitamin B12, vitamin D are just some, some of the ones that research has shown to be common. So rather than start off right away by eliminating something, we, our team likes to begin by expanding a child's diet. So let's begin to expand nutrient-rich foods so that we can get to a point where we can eliminate certain foods safely and then see whether a child would benefit. 

DR. AMY: So is it a sensory issue that limits their diet? Is it like the texture that keeps them from wanting certain foods or is the taste off putting? What is happening there with having this limited number of foods? 

DR. GOH: So the sensory factors are the most important ones. So, yes, much of the restricted diet that we see in autism relates to hypersensitivities. So, to certain tastes, to certain textures. And then also part of it relates to the more sort of restricted, well, differences in terms, when it comes to flexibility. So, a tendency to like things to be more predictable and the same. And so one of the examples we'll give sometimes is we'll say, okay, if you take a Goldfish cracker, every time you eat a Goldfish cracker, you can be really sure it's going to taste the same way you take a blueberry. Each time you eat a blueberry, it could be quite different texture, the taste, the sweetness and sourness. And so that's one of the reasons why processed foods by some children will, you know, tend to eat only processed foods which we know have less nutrition and have ingredients that could even be pro-inflammatory, you know. So there are a number of reasons, both sensory and also more related to sort of the cognitive flexibility component.  

TERI: This is so eye opening. I'm just, my mind is exploding with like, oh my goodness. I've seen that. I've seen that. Yeah, the three kiddos that I know I need to pursue getting that official diagnosis. An interesting thing, eating wise, I've seen in all three of them, is they cannot tolerate getting dirty. Getting up dirty, messy, getting messy, like with their fingers. So if it's anything like a finger food or, you know, like chicken wings. Oh, no, that would be a nightmare. Anything that is, they can't just deal with like a fork and they don't, it's not going to get around their mouth. And so interesting that I've not made that connection until you just said this.  

DR. GOH: Well, you know, there's an approach to feeding that we use in our clinics called S.O.S. that is very sensory based. So really understanding a child sensory profile and then from there, then helping them to expand their food intake. But one of the steps involves, you know, touching, playing with food. And so I think parents sometimes see that as a negative, like most children “don't play with your food,” but for some children, it's an important step towards then being able to eat a wider variety of foods.  

TERI: This is amazing. 

DR. AMY: Is this a gentle approach? Is this an approach that creates this, these, you know, visceral, aversive responses in kids, or is it slow and methodical? Like, I'm fascinated, but also wondering what that looks like. 

DR. GOH: Yes, yeah. So the answer is yes, it is a slower, more methodical approach that is really trying to understand and, and prioritize the child's experience of the foods, you know. So what is it about their experience that leads them to resist? It's because they're experiencing certain foods in an aversive way. And historically, the approach was much more sort of forcing, you know, sort of assuming that a child wasn't eating it because they're being non-compliant. And then that, of course, led to certain techniques to feeding that caused quite a bit of trauma for children. And just imagine, I mean, think about your own taste, your own preferences. Imagine being forced to eat something that you find aversive. We all have those things. You know, for some people, like imagine eating liver, you know, or whatever food it is that, you know, makes you want to catch.

DR. AMY: The Lucky Charms marshmallows that squeak. I can't do it.  

DR. GOH: We all have something and it's helpful to put yourself in the shoes of the child. So for that child, it's just more things. And so, what could be worse than forcing, you know, a child? You're not going to reach a point. You're not going to get to where you want to get to by forcing a child and having them experience eating in a traumatic way. So the approach does need to be gradual and more thoughtful. 

TERI: I know we're almost out of time and I know we need to wrap this up, but I just have to ask this last question. And this is, this is interesting because it's, it's kind of what I've described here, just totally coincidentally. I talked about my firstborn, my oldest son, different cause epilepsy, different, I think, you know, score reason or whatever. And then my 18-year-old son and my grandson. What about, why do I think there's this, this theory that autism is more prevalent in boys. And yet my daughters, my grown daughters have said, no, that is not true. They've said, don't believe it. I think I struggle with it too and they've said, I think it's that girls mask it because girls are sort of forced and taught to be pleasing, to be sociable. So speak to that, that seeing autism more often in boys. 

DR. GOH: Yes, well, we're what we've we're realizing now, it used to be thought that autism was four times more common in boys. Now we understand that it's just that we have not been as good at understanding it and diagnosing it in girls. And so it's very likely that the prevalence is, the frequency is the same, it's just that it looks different in girls. And in girls it will tend to be sort of interpreted as shyness. And as you said, girls will tend to mask more and they'll turn tend to imitate, they'll learn sort of they'll observe and they'll learn what needs to be done and they'll do it, even though it's not their natural tendency. And so, yeah, we've learned a lot about this over time. And we've also learned that our diagnostic assessments, standardized assessments that are used for autism diagnosis are much more skewed to detecting the features in boys than girls.  

DR. AMY: Well, and we, we saw that with ADHD diagnoses too. Right? I mean, we were diagnosing hyperactive boys, you know, in the ‘70s and ‘80s. And we were missing the inattentive type in girls because we didn't see the same behavioral manifestations. Right. And so the more we learn, the better we get.  

TERI: So good. This is just, this is amazing. This is why yes, two part. This is so good. 

DR. AMY: So listeners, this, like Teri just said, this is the first part of our talk with Dr. Suzanne Goh on autism. Please tune in for part two where we really dig into those elements of her whole-child path, brain, body health, and development, behavior, family, and community, and what that looks like in supporting autistic kids. And so, we are going to put a link to her book, “Magnificent Minds, The New Whole Child Approach to Autism” in the show notes, along with links to her website and social media so that you can find out more about Dr. Suzanne Goh. Thank you so much for being with us today. We can't wait to have our second conversation with you, Dr. Goh. 

DR. GOH: Thank you. Thank you so much.  

DR. AMY: Listeners, thank you for being with us today. Please find us on Instagram and Facebook at The Brainy Moms. Follow us before you forget. If you'd rather see our faces, we are on YouTube at The Brainy Moms. And if you love us, please rate us on Apple Podcasts. So look, this is all the smart stuff that we have for you today, and we are going to catch you next time. 

TERI: See ya.