Intro: Edward S. Brodkin M.D. is Associate Professor of Psychiatry with tenure at the Perelman School of Medicine at the University of Pennsylvania. Dr. Brodkin received his A.B. from Harvard University and his M.D. from Harvard Medical School. He then completed an internship in pediatrics at Yale-New Haven Medical Center and a residency in psychiatry at Yale, where he conducted clinical psychopharmacology research in autism spectrum disorders. He went on to a postdoctoral fellowship in basic neurobiology research at Yale in the laboratory of Eric Nestler, M.D., Ph.D. and a second postdoctoral fellowship in genetics research in the Department of Molecular Biology at Princeton University in the laboratory of Lee M. Silver, Ph.D.
Q: Tell me a bit about yourself: your background and what you do at this point in your career.
A: Sure. My name is Dr. Edward Brodkin. I’m a faculty member at the Perelman School of Medicine at the University of Pennsylvania and Penn Medicine. I’m an associate professor of psychiatry, and I focus my clinical work and my research on autism, especially the transition to adulthood and adults on the autism spectrum. I’ve done research on neuroscience, genetics, and treatment development and testing for people on the autism spectrum.
Q: Why did you choose to be a psychiatrist?
A: Well, I was really interested in science and medicine from a young age. And I had an interest in human behavior. And then in medical school, I got really interested in neuroscience and the way the brain works. I found that really fascinating in the first two years of medical school. And then, in the second two years of medical school, when students do clinical rotations, I really enjoyed psychiatry, I found the patients very compelling, and I felt motivated to help. And so I liked psychiatry clinically, I also liked the research aspect of it, because there’s a lot that’s still not known about the way the brain works and behavior and how we can best help patients with psychiatric issues. And then I got interested in autism during my psychiatry residency when I worked on a unit that had an adult Autism Clinic. I got to work directly with adults on the autism spectrum. And again, I really felt like I had a lot of desire to help and a desire to better understand their experience and better understand the workings of the brain and autism as well as just better ways to be helpful to them.
Q: You graduated with an undergraduate degree in history; can you talk a bit about your career path and how you decided to go to medical school?
A: I majored in the history of science. And I had always had an interest in both science but also social sciences, history, humanities. So I felt like majoring in the history of science was a nice opportunity in college to take some history courses to take some science courses in the history of science. And I really enjoyed that. I think some students early on, like in high school, think that to go to medical school you have to major in biology or major in pre med, but that’s not really true. You can major in something else, as long as you take the pre med courses.
Q: What does ASPE do, what are its goals, and how does it try to achieve them?
A: ASPE is a program at Penn Medicine. It stands for the Autism Spectrum Program of Excellence. And it is a project that’s a collaboration among 11 different laboratories at Penn, including faculty members in the departments of genetics, neuroscience, and psychiatry. The overall goal of ASPE is to better understand autism and better understand the biological basis of autism. A lot of ASPE is focused on genetics, because there is a large genetic component to many forms of autism. The ultimate goal of ASPE is to improve the quality of life for people on the autism spectrum. A newer part of ASPE that we’re developing is clinical trials, developing new treatments and then testing the effectiveness of those treatments.
Q: You mentioned that one of the goals is to increase the quality of life for people with autism.
Could you talk a little bit about how doing genetic research contributes to that?
A: Well, we know that autism is very heterogeneous, which means that autism isn’t really one thing. We have one word for autism. But we think there are many different sorts of biological processes that underlie what we call autism. To come up with better ways to help and better treatments, we need to understand the diversity of biological processes that are contributing to autism, for example, the many genes that contribute to autism. And by understanding the biology better, we can then come up with better ways of treating or personalized ways of treating. We need different kinds of treatments for different kinds of people, depending on the underlying biology. So as one example is that in ASPE, we’ve had a strong interest in a gene called Neurexin 1. We’ve recruited people into our study who have deletions of part of the Neurexin 1 gene. Now, there are many other genes involved in ASPE in autism, but it may be that treatments for people with Neurexin 1 deletions or copy number variants would be different from the optimal treatment for someone with autism but with a different kind of underlying genetic basis.
Q: One really important goal for people with autism is societal integration. What are some ways to encourage and support that societal acceptance for people with autism, and how can we especially, as high schoolers, help with that?
A: That’s a really important issue. And this is the month of April, which has been called Autism
Awareness Month, and now, many people are preferring the term Autism Acceptance Month. And I think that’s a very important issue that needs to be increased — societal understanding and acceptance, and really welcoming of autism, and neurodiversity. So I think, really, a lot needs to be done in terms of educating the general public. And that includes young people in high school and college, but even adults on the topic of neurodiversity and autism. What are some of the challenges that people on the spectrum face but also what are some of the talents and strengths that they bring? And we need to promote understanding, welcoming, acceptance of a diversity of people and appreciating their strengths and being willing to provide support for some of the challenges they face. And so I think that kind of education should start early, in middle school and high school. A lot of people on the spectrum have experienced bullying or exclusion, social exclusion in their years in school. And so number one, I think, is to better understand the spectrum, and there needs to be an orientation against bullying, and more acceptance and inclusion. I know that a growing number of high schools have neurodiversity alliances, and are trying to raise awareness, understanding and acceptance of neurodiversity, and I think that’s great. I think there needs to be more of a conversation around it. And greater education.
Q: I run the Neurodiversity and Disability Association at my school. And I think the main thing that I do is that I present acts about various conditions. But what I’m facing is that, while that’s probably a good way to create change and awareness, people are still very, very stuck on the conditions and make fun of them. This might be because they don’t know some of the aspects that people with autism may go through–the full picture. For example, an individual with autism may face a lot of social exclusion. But then, people make jokes about people with autism a lot; they might not realize that. So, could you please talk more about both autism excellence and also some of the challenges that people with autism and their families may face?
A: Well, I think you described it really well, some of the challenges. Many people have difficulty understanding or accepting people who are different from themselves, especially during adolescence and high school. It’s a time of development when people are figuring themselves out and where they belong socially. So it really is a challenge. And I think it’s great, what you’re doing. School administrations should promote an atmosphere of understanding of kindness, of compassion, of trying to understand other people’s experiences that may be different from one’s own. There needs to be greater understanding of repetitive behaviors, or stimming which is often an effort of people on the spectrum to regulate themselves, or a way of expressing excitement. There needs to be a greater understanding of the great qualities that people on the spectrum have. There are misconceptions about people on the spectrum, for example the idea that they don’t want connection, or they’re not interested in friendship. And that’s really not true for the vast majority of people on the spectrum. Most are interested in forming friendships, and can be really loyal friends who are kind people and very genuine. So for schools, I think it comes down to culture, creating a culture of kindness and openness and acceptance and compassion rather than exclusion. And I think organizations like the one you are leading really help to foster that spirit of inclusiveness. I hear what you’re saying, there’s still a long way to go. But I think it’s great what you’re doing, because I think sometimes for high school students, when that comes from other young people in your class from your peers, that’s really powerful. Instead of just coming from teachers or authority figures.
Q: I wanted to go back to something you said about stimming. So a couple of weeks ago, I presented a slideshow on autism. And it came time to describe some of the symptoms. And I tried to describe stimming, but some of my classmates still couldn’t understand it. Do you think that you could please try to describe it in a better way?
A: I often think of stimming as a way to self-regulate, to regulate emotions. We all have times when we have strong feelings and emotions, and maybe we feel stressed or maxed out. And we have ways of coping with that. I think teenagers would generally understand that. And different people have different ways of coping with that. And so stimming can be a way that people on the spectrum regulate their level of emotions at times when they feel maxed out, or sometimes when they feel just really excited. Also, people on the spectrum may feel overwhelmed by certain things that don’t bother others as much like, for example, sensory stimuli, like bright light and certain sounds. In a high sensory environment, they may get maxed out and need to regulate either by stimming, or maybe even by removing themselves in that environment for a little while. Also, even though they may want connection, being in a really high social demand environment in which people need a lot of responsiveness may be a lot for them. And so I think it’s important to educate students and school administrators on what can make autistic people feel overwhelmed, and how to help them if they are feeling overwhelmed. I think those kinds of things could be helpful. And presenting the idea that we all need to find ways to self-regulate can make it more relatable. So even if the manifestation of it, the stimming, looks different from what neurotypical individuals might do, we all can all feel stressed and overwhelmed sometimes, and have a need to self-regulate.
Q: I wanted to go back to something you said about autism being very heterozygous. I don’t know if you watch this movie–it’s called Rainman.
A: With Dustin Hoffman? Yes, yes I have.
Q: Okay great! Could you talk a bit more about both the positives of demonstrating one manifestation of autism behavior and also the dangers of trying to portray autism solely in one way?
A: Yeah, well, I think it’s what you just said. I know there has been some controversy about that movie. Because on the one hand, perhaps it raises some degree of awareness about autism, but I think others feel that it may have fed into certain stereotypes of what an autistic person looks like. And, like you’re saying, there’s a lot of variability among people on the spectrum. Not every autistic person looks like the rain man in that movie. So we have to be careful about stereotyping. And in fact, there are people on the autism spectrum who may seem indistinguishable from neurotypical folks. So I think having one fixed stereotype of what someone on the spectrum looks like or behaves like is hazardous. So we just have to be careful about that.
Q: Is there a treatment for autism? What are the new developments for this?
A: Yes, but we have to go back to the idea of variability among autistic people. There’s no single treatment, as in, there is no universal treatment for everyone on the autism spectrum. It really depends on the specific issues that that particular person is facing. There are the core defining features of autism, which are challenges around social interaction as well as restricted, repetitive, stereotyped patterns of behaviors and interests, as well as sensory sensitivities. So there are treatments that could be targeted at those. But then there are a lot of associated things that sometimes occur with autism, such as depression, anxiety, attention deficit hyperactivity disorder (ADHD), things like that. And so when you talk about treatment and autism, you have to come up with a personalized treatment plan for the particular person, like what are the specific issues that this person is facing? What are the most important issues? Often treatments are focused on the associated symptoms like anxiety, depression, ADHD, and we do have fairly well established treatments for those associated conditions. Sometimes they’re non medication treatments like therapy, cognitive behavior,therapy, behavioral therapy. Sometimes they are medication treatments for anxiety or depression or ADHD. In terms of the core, defining features of autism, there are not really medications that are really well established. So treatments for the core symptoms are cognitive-behavioral or behavioral treatments. A neurodiversity framework for thinking about treatment is that the goal is not to eliminate autism, but rather to improve the person’s quality of life, to help them achieve their goals, and to reduce distress and suffering and maximize their potential. There is a need for a lot more research on treatment at all stages of life, and autism. And there’s more work being done to refine behavioral and cognitive behavioral treatment programs, there’s more work being done on clinical trials of medications. I think using the genetic and neurobiological research that we talked about earlier, better understanding the biology of the autism spectrum could lead to new, really novel approaches to biological treatments for some aspects of autism.
Q: Some individuals that I know who are neurodiverse talk about how they take medication, and then they experience side effects. And they try something new, and then there’s a whole new set of side effects. And then they stop the medication and experience the original symptoms from their condition. Can you talk more about why it can be really hard to medicate people who are neurodiverse?
A: Every medication, whether it’s for autism or any other condition, comes along with potential side effects. And it’s really important for people and families who are considering medication to talk with the doctor about the potential benefits and potential adverse effects of this medicine. Some medications come with more potential adverse effects than others. Sometimes, to be frank, it’s a trial and error process to find a medication that is working well, that doesn’t have too many adverse effects. The other issue, which I think maybe your question is suggesting, is that people on the autism spectrum may be more sensitive to some of the adverse effects of some medicines than neurotypical people. And so, sometimes it’s necessary to start with lower doses and if doses are increased, just go gradually so that you can minimize the adverse effects and hopefully have more of the benefits without the adverse effects of the medicines.
Q: I know that one symptom of autism is concurrent stomach problems. Could you talk more about why that potentially happens?
A: Clinicians and families have noticed for decades now that many people on the autism spectrum have gastrointestinal symptoms such as stomach pains or digestive issues There are hypotheses about alterations in the microbiome in autism, that is alterations in the bacteria that live in our lower intestines. And the nature of the microbiome could potentially contribute to gastrointestinal issues, maybe even to behavioral issues. Another issue is that many people on the autism spectrum are picky eaters in early childhood. And so, it’s a bit of a complicated problem, right? Because what we eat, and the variety of our diet affects our microbiome and the microbiome, in turn, it affects our gastrointestinal functioning, and so on. There are a number of eating issues and gastrointestinal issues that sometimes come along with autism. And I think it’s complicated, but it definitely affects quality of life. We need more research on that.