April 10, 2025
Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen.
Autism diagnoses have increased in the last several years. Why is that? Join us for this episode as we explore the nuanced world of neurodevelopmental disorders and how several conditions can present with symptoms that mimic Autism Spectrum Disorder. Our CHC expert licensed psychologists, Dr. Whitney Geller and Dr. Neilsen Chan, discuss the core features of autism, things like social communication challenges, restricted interests and repetitive behaviors, while examining why diagnosis rates have risen dramatically in recent years. So listen in as we talk about how other conditions like ADHD, anxiety disorders, and more can sometimes be mistaken for autism due to overlapping behavioral presentations.
Welcome Dr. Geller and Dr. Chan. Before we dive into this conversation today, could you take a minute to tell our listeners a little bit more about yourselves?
Whitney Geller, PhD: My name is Dr. Whitney Geller. I have a PhD in clinical psychology with a specialization in neuropsychology. I’ve actually worked with individuals across the lifespan, but felt like my heart was really in pediatrics in the end, so, pursued further training into pediatric neuropsychology where I’ve worked in hospital settings and now at Children’s Health Council, where I conduct evaluations with children for a variety of reasons. ADHD, autism, learning disorders, mood, behavioral problems, and then every once in a while, some medical cases where they need to have a little better understanding of the cognitive profile of children with serious medical problems.
Neilson Chan, PhD: And my name is Dr. Neilson Chan. I am also a licensed psychologist. What I do here at Children’s Health Council is I conduct evaluations and evaluations involving questions about autism are some of my favorites. Prior to joining CHC, much of my work has been in research, focusing on families of children with autism. So, this is a population that I care very deeply about, and I’m glad to join Dr. Geller and Cindy here today to talk about this topic.
Cindy Lopez: Wow. Thanks so much, Dr. Geller and Dr. Chan for joining us today. I know that your expertise and insights are going to add a lot to our conversation today. So I’m excited about that. Before we dive into kind of the questions around autism, let’s first describe or define what it is. Can you talk a little bit about that?
Whitney Geller, PhD: Well, isn’t that the million dollar question. I think that this is actually a seemingly easy question, but in reality, it’s actually a pretty difficult question to answer because frankly there’s a lot of debate, even amongst experts in our field, and there’s still a lot of research being done. There’s not like a one-to-one cause genetically or neurobiologically, there’s not an autism part of the brain or something like that. It can’t be reduced to something like that. So, experts in the field have spent a lot of time trying to figure out, well, what exactly is this?
Neilson Chan, PhD: So within the clinical context, one of the ways that clinicians might diagnose autism is based on what we call the DSM. This is a Diagnostic and Statistical Manual that we use to describe various conditions. And in the DSM, there are very specific criteria that need to be met in order to diagnose somebody with autism. Now, one thing just to consider is that autism is what we consider a neurodevelopmental condition. What that means is that autism can really present very differently across the lifespan. However, there are still very specific criteria and behaviors that we use to anchor and to define what autism looks like. So broadly speaking, there are two different buckets of behaviors that the DSM describes. One is what we call differences or deficits in social communication and social interactions, and I’ll talk a little bit more about what that means. The other bucket of behaviors is what we might call restricted interests and repetitive behaviors.
Now going back to the first bucket that we talked about in terms of deficits in social communication and social interactions, again, what that looks like from person to person might be very different. But what we might see might be things like differences in what we call social and emotional reciprocity. There might be some differences in terms of conversations in terms of how they flow or maybe in terms of how a person on the autism spectrum might express their emotions or how they might understand emotional expressions in others. There might be differences in both verbal and non-verbal communication. So we might see things like differences in how somebody on the autism spectrum might make eye contact or maybe differences in terms of how they use their bodies to gesture, to communicate. Maybe we might see some differences in how facial expressions are directed at individuals. Another aspect of some of these differences in social communication and social interactions might be differences in how the individual understands or has insight into the nature of certain social relationships. In younger children, this might come across as differences maybe in how they play with other kids, or as a person grows up, maybe differences in how one might approach a friendship in terms of how they understand some of the nuances of what makes a friendship, for example. All of these are things that we might see, different behaviors that we might see that kind of fall under this bucket of differences in social communication and social interactions.
Now, the second bucket of behaviors also consists of a variety of different behaviors when we talk about restricted interests and repetitive behaviors. For some individuals on the autism spectrum, we might see a very strong interest in certain topics. We might see what we call insistence on sameness. Maybe having some difficulties with transitions in routines. Maybe we might see certain kinds of repetitive behaviors, such as repetitive motor behaviors. You might see some people on the autism spectrum maybe flapping their hands or rocking their bodies, that kind of repetitive behavior, or we might see some repetitive speech patterns, some things like what we might call echolalia, or you might see some individuals on the autism spectrum, maybe repeating certain phrases or things that they have heard before. We might see certain kinds of sensory sensitivities or sensory aversions in individuals on the autism spectrum. And so, as you can see, there are really a whole host of different behaviors that really go into the diagnostic criteria for autism.
Cindy Lopez: It’s interesting hearing you both talk. So listeners, I’ve said this before, but my experience is all in education. So I’ve been working with students for decades and definitely as you were both talking, both Dr. Geller and Dr. Chan, I was picturing some of the students that I have known over the years and it’s interesting because some of those were diagnosed with autism and some were not, which makes me think like how prevalent is autism? I mean, you described a lot of behaviors that could be maybe not autism, but just part of the person’s repertoire of how they respond. So, what can you say about the prevalence of autism?
Whitney Geller, PhD: I think you bring up a really good point – prevalance – and something interesting that’s happening in the research field. So, Dr. Chan described this categorical approach that we’re using in the clinical world right now, where we’re kind of putting people in a box and giving them a label based on a set of multiple symptoms. Well, that actually poses a lot of problems when it comes to research and part of what may be resulting in this diagnosis versus not diagnosis, and there’s actually a movement to start studying autism in a more dimensional way. So, for instance, probably the most prominent method for studying that’s dimensional is the research domain criteria proposed by the National Institute of Mental Health, which really breaks it down into its parts to help provide more precision and the ability to identify genetic and neurobiological correlates of autism.
So, by breaking it down into proposed positive and negative symptoms and cognitive dimensions. So, for instance, the positive features could be something like repetitive behaviors, echolalia, or circumstribe interest, something that’s being added that you wouldn’t necessarily see with a neurotypical child. And the negative features would be something like, lack of eye contact or lack of ability to engage in a reciprocal conversation. Something’s not there that would normally be seen in a neurotypically developing child, and then cognitive features that we usually think of are like the rigidity, impaired intention is also often seen in autism. And I do want to highlight that, you know, regardless of categorization of autism, and how it’s studied, at the heart of autism, which I think Dr. Chan highlighted, is really challenges and social communications and that pattern of restricted and repetitive behaviors. And so, just taking that caveat of we’ve kind of moved in different directions with how to define autism, I think is a good point to be made about the prevalence. So, for instance, in 1966, the autism prevalence of diagnosed autism was 0.05%, so very, very low. And then the most recent data from the CDC, from 2020 is now saying that the rate is 2.8% so 1 in 36. So that’s a pretty big jump. So there are a couple of theories about what’s going on here.
Cindy Lopez: Wow. Dr. Geller, as I think about what you just said, in terms of in 1966, .05 % of the population was diagnosed with autism. And now, or in 2020, 2.8% that seems like a big jump. Why do you think that is?
Whitney Geller, PhD: Yeah. I think one of the big causes is in 2013, we lumped a bunch of different diagnoses together under the autism spectrum umbrella. So, we previously had separate disorders, but now we have included in autism spectrum: Asperger’s syndrome, child degenerative disorder, and pervasive developmental disorder. They’re now under the autism umbrella. So that caused a bump for sure, and then there’s a lot of people that argue that one of the reasons for the increases is that now we have better awareness and better identification, and we’ve got all this great new research with these dimensional approaches, helping us identify these individuals and get them treatment.
There is a little bit of conflicting information out there. So, for instance, there was a study by Bloomberg in 2016 that noted approximately 13% of children ever diagnosed with autism were estimated to have lost the diagnosis, which could suggest a problem with incorrect diagnosis or over diagnosis. So there definitely is some conflicting information out there about whether it’s merely better diagnosis or over diagnosis because as Dr. Chan mentioned earlier, autism is a neurodevelopmental disorder, meaning that it’s not going to go away. If you met criteria, it should theoretically be present for life.
Cindy Lopez: Well, that’s interesting. So, speaking of over diagnosis or better diagnosis, it seems like then we would want to be looking at what is it that is autism and could some of the descriptors that we have already mentioned also be used for other conditions?
Neilson Chan, PhD: Yeah, absolutely, Cindy.
So earlier when we were talking about some of the behaviors to anchor a diagnosis of autism, we were talking about things like challenges with social interactions. We’re talking about challenges with communication or repetitive behaviors or some restricted interests, sensory sensitivities. These are behaviors that are certainly part of a diagnosis of autism. And at the same time, we also see some of these behaviors in typically developing children or we may also see some of these behaviors in other conditions that we might diagnose. And so this is when it becomes really important, again, to keep in mind that there must be a long standing pattern of a cluster of these behaviors that cause functional impairment in order to meet the diagnostic criteria for autism. Now, one of the things that is interesting that often comes up whenever a parent raises a question about whether their child might be on the autism spectrum is that there are actually quite a few things that can mimic autism.
Whitney Geller, PhD: I would also argue that a lot of these things aren’t exclusive to autism. I think that you make a really good point that it can mimic it and that it’s not actually autism. And, the sensory sensitivities, for instance, occur in tons of kids.
Cindy Lopez: Yeah, and as an educator too, and I started out in early childhood, I see those sensory things in young children all the time, that doesn’t necessarily mean they have autism or they need a diagnosis. I feel like at different developmental stages, we might see some of these behaviors more in typically developing children more than at other times.
So, going back to your comment that I think Dr. Geller, you, made earlier, one of the things that we see a lot in kids with autism is challenges around social interactions. So, let’s think about that arena for a minute and how that can go either way.
Whitney Geller, PhD: Yeah, I think you bring up a very good point because one of the hallmark features that we associate with autism are the social difficulties. And I think that some of the ones that I come across the most with parents coming to me and being concerned are like, poor eye contact, difficulty picking up on social cues, a lack of reciprocity and conversation, less emotionally expressive, which as clinicians, we usually call this a flat or restricted affect, where they’re just less emotionally expressive or maybe have less use of gestures or non-verbal communication. Those are some of the things that I often get parents concerned about.
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Cindy Lopez: So Dr. Geller, I’m hearing from you that there could be lots of reasons that kids may have social challenges. Could you describe or give some examples of those?
Whitney Geller, PhD: Yeah, so, for instance, kids with language disorders often have difficulties with either speech production or understanding what’s being said to them. And of course, that would make anyone self-conscious, right. It’ll make you less likely to talk. You might become anxious or avoidant of social situations because frankly, language is just hard and that’s a large basis for how we get along and socialize with other people. ADHD, for instance, I see all the time with my ADHD kids that they just can’t sustain eye contact because they’re so distracted and all over the place that they have a hard time making eye contact, or it’s very fleeting. They also have a hard time tracking in conversations because they’re distracted or they interrupt, or they might even have social transgressions against peers where they do something or say something they probably shouldn’t because of that impulsivity piece.
I think that it’s also important to note that there are a number of mental health causes that can look similar to autism socially. So anxiety is one of the big ones. Kids and adults with anxiety, especially social anxiety, it’s really hard to sustain eye contact. It’s hard to know what to say in a conversation. It’s hard to even get up the motivation to go do something social because it is so anxiety-provoking and that can look a lot like autism because there’s the social avoidance. There’s the hard time in conversation. There’s the lack of eye contact. Same thing, depression a lot of times manifests as like, low social motivation, maybe even some avoidance of eye contact there. Children with trauma, certainly have a hard time with eye contact. They can also have a hard time reading social situations or understanding social cues because they’ve got kind of a different life experience and different view of the world. They might have a hard time with the typical social cues and understanding them.
Cindy Lopez: And Dr. Chan, you mentioned earlier, like the arm or hand flapping and I think that those are typically some of the behaviors that we might associate with autism and what I’m hearing is that those behaviors could be associated with other things too.
Neilson Chan, PhD: Right, so we talked about some of these repetitive motor behaviors, you know, the hand flapping. Some children may rock their bodies, or walk on their toes, or focus repetitively on certain parts of their body, and certainly this is part of the diagnostic criteria for autism, but we also see these behaviors in children who don’t have a diagnosis of autism as well. For example, we might see some tics in somebody who has a diagnosis of Tourette’s or a child who might be anxious might engage in some of these repetitive behaviors to self-soothe. Oftentimes, my kids with ADHD might also tell me, yeah, I need to kind of expel some of that energy through moving my body or we might see a child with OCD engage in certain types of repetitive behaviors as part of that condition. And so certainly, some of these repetitive behaviors, these self-stimulatory behaviors, we might see them in other children, as well.
Cindy Lopez: Yeah, I think about some of the students that I knew with autism. Another piece that I think of is the inability to kind of flex with the situation. So a little bit of rigidity. And listening to what you’re saying, both of you, I’m like, oh, wow. So that probably is prevalent and other types of conditions or disorders as well.
Whitney Geller, PhD: Yeah, absolutely. I mean, don’t we all have our times when we’re a little bit rigid? I certainly do. So I think that again, that highlights that this can occur in anyone, right, neurotypical children, children with other disorders, and things going on. And I think that rigidity and even the circumscribed interest. So Dr. Chan mentioned that earlier with kind of these restricted intense interests that also tends to be a hallmark feature of autism. And we do actually see that in other kids as well. Typically, I would say that the intensity of it is a little bit less in the other disorders, and tends to be more flexible over time. So, I think that that might be kind of one of the things that presents a little differently in autism versus not autism populations. But I think that it is very clearly apparent in, for instance, say ADHD, we get the kids that are really hyper-focused, right, kind of an all or nothing with attention. So either they’re inattentive or they’re hyper-focused. And those times when they’re hyper-focused, it can really feel like autism. They’re not necessarily responsive to you. They’re very, very intensely interested in something. They can’t break away from it. And they’re very rigid about a lot of things and even like routines and stuff and needing to adhere to routines. You also see that a lot with like OCD and anxiety where that need, that craving of routine and sameness is pretty prominent, which I think makes sense too with a lot of these things. These kids are trying to make sense of the world. They’ve got anxiety or ADHD or OCD, something that’s making it more of a struggle for them. And they’re just trying to navigate and rigidity is kind of an easy way to do that.
Cindy Lopez: For our listeners, I’m realizing that we’ve said, referenced, OCD a few times. So I just want to say if you’re not sure what that is, obsessive compulsive disorder, and we’ll probably continue to say OCD in different ways. I’m thinking about the sensory piece too, because that seems very from my perspective, hallmark-ish of autism, but again, based on our conversation today, not so.
Neilson Chan, PhD: Right, and I think the interesting thing about the sensory system is that it’s a really important system in our brain. And so whenever there is any kind of a neurodevelopmental difference, whether it’s autism or another condition, we commonly see differences in how we process sensory information. And so, differences in sensory processing are not uncommon, for example, in children who have a diagnosis of ADHD or other children with various developmental delays. And so, as a clinician, it is important for us to absolutely, yes, identify what those sensory processing differences are and to understand what the ideology or the source of these sensory processing differences might be.
Cindy Lopez: Yeah, I can’t stand having the tags on my clothes, like, they just bug me.
Whitney Geller, PhD: You and me both.
Cindy Lopez: So I’m sure there are lots of those kinds of things that are just part of a typically developing child as well.
Whitney Geller, PhD: Yeah. Beyond like neurotypical children too, I also think it’s worth noting that gifted children in particular, so these are the kids that may not meet diagnostic criteria for ADHD or another disorder–they notoriously have sensory processing differences, and they also tend to have some rigidity and some differences in their emotional and behavioral reactiveness. They tend to be a little bit more reactive than other kids that aren’t in that gifted range. And so I think that for them, sometimes the parents are seeing that they’re incredibly skilled at something or several things, and then coupled with like these sensory sensitivities, this rigidity and these outbursts. And it can look a lot like autism. We think about kind of the stereotype of the savantism in autism, coupling, and so for a lot of these kids, their parents come in concerned because they’re seeing all these symptoms that could be autism, when really it’s that their brains are processing things at, some might argue, at a higher speed and more intensely than others.
Cindy Lopez: And, thinking about that too, and we have a couple of podcast episodes on this, but kids who’ve been identified as twice exceptional, who are gifted and do have autism. So there is that too. There is that piece as well. So, all of this that you’ve shared today is so interesting, and it’s good to learn more about autism in this way, but I also have to ask, so what? For our listeners, how does knowing all of this help them support their children or their students?
Whitney Geller, PhD: I think that’s an excellent question because I think isn’t that always the question, right? Like you’ve got this diagnosis, what in the world do you do with it now? And I think that in particular differentiating between autism or something else, or sometimes, you know, it’s autism and being able to get that diagnostic clarification. One of the most helpful things that the diagnostic clarification can do is it can help to guide treatment. So, for instance in kids with ADHD, if it’s ADHD, we probably want to look at stimulant medications, depending on the severity, whereas if it’s anxiety or autism with no ADHD, a stimulant could actually make it worse or have no effect, but you wouldn’t necessarily want to prescribe a stimulant. So it can guide medical treatment and then behaviorally the aim of therapy is usually to treat kind of the underlying pattern. And so having some clarification about, well, is the underlying pattern more of like an ADHD or autism or mood disorder and being able to kind of target some more of the underlying root cause in therapy and tailoring therapeutic intervention to meet those needs.
Neilson Chan, PhD: Right. And one of the most common reasons why people come in for an evaluation, I mean really just to kind of reiterate Dr. Geller’s point, is diagnostic clarity and to guide next steps. And, we’ve been talking a lot about a lot of things that may look like autism, and the truth of the matter as well is that many things also overlap with autism. And so when we talked about ADHD, a high percentage of individuals in the autism spectrum may also have a diagnosis of ADHD. Or may also have a speech delay or may also be struggling with anxiety. And so, the better we’re able to tease apart what is what, what the etiology of some of these behaviors or challenges might be, the better it is that we can inform and tailor the types of supports that are going to be most helpful for your child.
Whitney Geller, PhD: One other thing that I do think is important too that can be particularly helpful from an evaluation in particular, is looking at what does the kid need in school? What would be helpful for the child in school? And so beyond just that diagnostic clarification, just figuring out what are the strengths and weaknesses so that we can get some help in school because kids are in school for a large portion of their day. It’s an important place for some kind of treatment or intervention to happen and I think that one thing that is really great when it can happen in autism, when it is autism, is early diagnosis. So I think that that kind of circling back to some of that beginning point of what about this rate increase and identification? You know, even if we’re identifying kids and catching kids that maybe ultimately don’t have autism for the ones that do have it, that early intervention is very helpful for long-term outcomes.
Cindy Lopez: Yes. And I think, for our listeners, they’re probably thinking now like, okay, you’ve now caused me to question whether or not my child may have autism or not. I thought maybe that’s where they were, or even they’ve been diagnosed, and I’m wondering now. So what should parents and caregivers be aware of and are there signs that they might see or not as they observe their child’s behavior?
Whitney Geller, PhD: Yeah, that’s an excellent question. And I think that it’s a hard one to answer, when do you seek help? When do you wonder what’s going on with your kid because yeah, you’re right. As we’ve discussed that it can be in typically developing kids, gifted kids, kids with other disorders. I think that some of the most important questions that I usually think about like, what’s an important question to ask, so how many symptoms are you seeing? Is it just the one? Is it just sensory sensitivities? If it’s only sensory sensitivities and nothing else, then yeah it’s probably not autism, but if you’ve got sensory sensitivities, social difficulties, and you’re seeing some restricted interests, that’s a number of different symptoms. Also, like, what is the frequency that they’re occurring? Is it you know, once a month – it’s probably, a little infrequent, but is it every day? That’s a big difference, right? Also, are the symptoms occurring in multiple settings? Because autism isn’t something you can turn on and off. It’s always there to some degree across the whole lifespan because it’s a neurodevelopmental disorder. So, in theory, the symptoms should be present across multiple settings – so home, school, other activities. and then how is that impacting your child at home, in school? How is it affecting them? Is it causing some kind of impairment? Is it impeding on the family dynamics? What is the impact of these challenges?
Cindy Lopez: Dr. Geller and Dr. Chan, thank you so much for sharing your insights and your expertise and experience. For our listeners, what do you hope they take away from this episode today, from this conversation?
Neilson Chan, PhD: One of the things that’s important to remember is that as parents, parents always have their child’s best interest in mind. And when they notice maybe a difference in their child or their child is struggling with something, it makes sense to want to understand why and how do I best help my child, right. And so, if you are worried, if you are concerned, or just wondering whether autism is part of the picture, or whether there might be something else that might be explaining some of your child’s behaviors or challenges, one of the best things to do is to reach out for a professional consultation. There are a lot of different professionals who can help answer some of these questions. Many of them are here at Children’s Health Council. So you might consider talking to a psychologist or consider talking to your child’s medical providers, maybe a pediatrician or a psychiatrist or a therapist who has specialization in some of these presentations.
Whitney Geller, PhD: Yeah, and I think that another important point to highlight that is not only true for autism, but across the board for everything is that the internet is full of misleading or just blatantly incorrect information, right? When in doubt, ask a professional because the information, some of it out there actually can be very anxiety-provoking for parents. I get parents that are panicked and coming in and worried about things that they read on the internet, and it’s confusing and it’s hard for them to process. So I think that really seeking help from a professional who has experience doing this is one of the best things you can do. And then, here we offer 30-minute free consultations to parents, which I think is a really amazing resource because you can literally speak to a professional for free to figure out if it’s even worthwhile to do an evaluation.
Cindy Lopez: So for our listeners, just want you to know expanding on what Dr. Chan and Dr. Geller said about seeking out help and professionals who might be able to help you. You can reach out to CHC. We’re here for you. You can reach out to professionals like Dr. Chan and Dr. Geller and others. You can reach us and our care team if you want to email, it’s careteam@chconline.org or you can call at 650-688-3625. And as Dr. Geller mentioned, we do have free parent consultations for 30-minutes. So you could come in and just talk about what you’re seeing, bring all the information you have about your child and get some advice and guidance regarding next steps. Dr. Geller, Dr. Chan, thank you so much for joining us today and to our listeners as well.
Whitney Geller, PhD: Thank you Cindy
Neilson Chan, PhD: Thank you.
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