Celine Saulnier, Ph.D. - Guest
Celine Saulnier, Ph.D., obtained her doctorate in Clinical Psychology from the University of Connecticut, after which she completed a postdoctoral fellowship and then joined the faculty at the Yale Child Study Center, Yale University School of Medicine. At Yale, Celine worked closely with Drs. Sara Sparrow and Domenic Cicchetti, investigating adaptive behavior profiles in Autism Spectrum Disorders. She became the Training Director and then Clinical Director for the Yale Autism Program, specializing in diagnostic evaluations of individuals with autism and related disorders across the lifespan. In 2011, she relocated to Emory University School of Medicine and the Marcus Autism Center to help develop and direct a large-scale clinical research program. In 2018, she opened her own diagnostic clinic and consulting company, Neurodevelopmental Assessment & Consulting Services (www.nacsatl.com) in Decatur, GA. Celine remains an Adjunct Associate Professor at Emory University, and she conducts national and international trainings to professionals on autism and related disorders. For her teaching, she was awarded the New England Educational Institute Outstanding Educator Award for Mental Health Education. Celine is on the editorial board for the Journal of Autism and Developmental Disorders, the Scientific Advisory Board of the Autism Science Foundation, and an Emeritus member of the Atlanta Autism Consortium's Board of Directors. In addition to co-authoring the Vineland-3, Celine has published numerous articles in peer-reviewed journals, and she has written two books, Essentials of Autism Spectrum Disorders Evaluation and Assessment and Essentials of Adaptive Behavior Assessment of Neurodevelopmental Disorders.

W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations.  He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy.  The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning.  This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy.  Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners.

Keith Sutton, Psy.D. (00:25): 
Welcome to Therapy on the Cutting Edge, a podcast for therapists who wanna be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training and evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on-demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our lifespan centers, Center for Children, and Center for Adolescents, where all the therapists are working systemically, our Center for Couples, where all the therapists are using emotionally focused couples therapy, and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma, and our Center for ADHD and Oppositional and Conduct Disorder Clinic, where we're integrating those four approaches.

Keith Sutton, Psy.D. (01:32):
In the Institute, we have our licensed experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com, and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501 nonprofit, so all donations are tax deductible. Today, I'll be speaking with Celine Saulnier, PhD, who obtained her doctorate in clinical psychology from the University of Connecticut, after which she completed a postdoctoral fellowship and then joined the faculty at the Yale Child Study Center, Yale University School of Medicine.

Keith Sutton, Psy.D. (02:34):
At Yale, Celine worked closely with Dr. Sarah Sparrow and Dominic Chachetti, investigating adaptive behavior profiles in autism spectrum disorders. She became the training director and then clinical director for the Yale Autism Program, specializing in diagnostic evaluations of individuals with autism and related disorders across the lifespan. In 2011, she relocated to Emory University School of Medicine and the Marcus Autism Center to help develop and direct a large-scale clinical research program. In 2018, she opened her own diagnostic clinic and consulting company, Neurodevelopmental Assessment and Consulting Services in Decatur, Georgia. Celine remains an adjunct associate professor at Emory University, and she conducts national and international trainings to professionals on autism and related disorders. For her teaching, she was awarded the New England Education Institute Outstanding Educator Award for Mental Health Education. Celine is on the editorial board for the Journal of Autism and Developmental Disorders, the Scientific Advisory Board for the Autism Science Foundation, and an Emeritus member of the Atlanta Autism Consortium's Board of Directors.

Keith Sutton, Psy.D. (03:42):
In addition to co-authoring the Vineland three, Celine has published numerous articles in peer-reviewed journals, and she has written two books, Essentials of Autism Spectrum Disorders Evaluation and Assessment, and Essentials of Adaptive Behavior Assessment of Neurodevelopmental Disorders. Let's listen to the interview. Well, hi, Celine. Welcome.

Celine Saulnier, Ph.D. (04:02):
Hi, how are you?

Keith Sutton, Psy.D. (04:03):
Good. Thanks so much for taking the time. I really appreciate it.

Celine Saulnier, Ph.D. (04:07):
It's such a pleasure to be here. Thanks for having me.

Keith Sutton, Psy.D. (04:09):
Yeah. So I know about your work. I did one of the PESI, uh, trainings on autism spectrum disorder advanced practices in evaluation, diagnosis, and treatment across the lifespan. And then we ended up-- I reached out and we did a Zoom. I was kind of asking questions. Part of my group practice, we were talking about kind of ways to put together an autism, you know, process for assessment diagnosis and kind of going through a screening process rather than maybe n- needing to jump into a full assessment right away. And so we had a nice conversation around that. So I, I thought it would be a great opportunity to talk more about autism and autism diagnosis because I think it's oftentimes very tricky. And I think myself as well as other clinicians, you know, are trying to kind of figure out how to help best support their neurodivergent clients.

Keith Sutton, Psy.D. (05:03):
Before we even get into that, I always like to hear about people's, you know, kind of evolution of their thinking, how they got to doing what they're doing.

Celine Saulnier, Ph.D. (05:11):
Sure. Well, first of all, thanks for attending that PESI workshop, and I'm glad it was helpful, and I loved being able to meet you through that. Especially when you do Zoom these days, you don't have that connection the way you-- if you were doing an in-person workshop where you can come up to somebody and talk to them face-to-face. So I love that you reached out. And as far as my history, I'm a clinical psychologist by training, but solely with the interest in autism. So even when I was going into graduate school, I knew I wanted to be in the field of autism. It's just that most of the researchers and clinicians working within that space were in clinical psychology programs. And I ended up going to the University of Connecticut to train with Debbie Fine, who is now retired. She's, for those of you might heard her name, the developer of the MCHAT, the world's most widely used screener for autism.

Celine Saulnier, Ph.D. (06:12):
And I trained with her, and then I went and did a postdoctoral fellowship at the Yale Child Studies Center with a wonderful group in their autism program. So Ami Klin, Fred Volkmar, Kasha Havasca, Sarah Sparrow, and then ended up staying there for almost a decade. And then in 2011, my mentor, Ami Clin, was recruited to Emory, and I came with him, and that's how I got to Atlanta. And then in 2018, I decided to kind of do a 180 in my career and left academia and went into private practice and have my own consulting company and clinic here in Atlanta, and it's called Neurodevelopmental Assessment and Consulting Services. But I still have an adjunct faculty position at Emory. I still stay actively involved in academia. It's just not my full-time job.

Keith Sutton, Psy.D. (07:05):
Yeah. Well, wonderful. Great. And another little tidbit too that I heard you talk about in the training is your work with the, creators of the violin and adaptive behavior scale, which, you know, is something that I learned about in graduate school. I hadn't necessarily used it much with clients. Can you speak a little to that also, because I think that was really interesting.

Celine Saulnier, Ph.D. (07:26):
Sure. When I went to Yale as a trainee, right, fresh in my postdoc, Amy Clin worked very closely with Sarah Sparrow, the author of the Vineland. And her husband, Jom Cichetti, co-author, was the biostatistician. They had developed the Vineland prior to Pearson owning it. And then when Pearson acquired it, that was in the development of the second edition. So when I got there, Sarah Sparrow and Dom and Fred Volkmar and Amy Clin, they were all doing research on adaptive behavior profiles in autism and intellectual disabilities, and I loved it. So I got really involved with them, writing papers and doing research on these profiles, even though I was also simultaneously focusing on early detection and other aspects of autism research. But because of my work with Sarah and Dom, that lasted nearly 10 years, right around the time that Amy was being recruited to Emory and we were making this decision whether to relocate, Sarah Sparrow got suddenly ill.

Celine Saulnier, Ph.D. (08:38):
And passed away. And that was in 2010, right when Pearson was about to develop the third edition of the Vineland. And unbeknownst to me, she had discussions with Ami and Dom and said, "I would like Celine to take on the authorship of the Vineland," which blew me away. Wow. I mean, I was still fairly junior in my career. And so I ended up working with Pearson to develop the third edition. So in 2018, Dom Chachetti sadly passed away. So now I'm the sole living author of the violence. And it's such an honor to carry on the legacy.

Keith Sutton, Psy.D. (09:14):
Yeah. Yeah.

Celine Saulnier, Ph.D. (09:16):
It's very precious to me. And I still do a lot of work in, in researching adaptive behavior profiles and teaching and training on it and consulting.

Keith Sutton, Psy.D. (09:26):
Yeah, definitely. And for those that don't know or don't do the testing, the vineland's very essential in diagnosing developmental disabilities, right? Kind of looking both at the intellectual abilities and where that falls, and then also their behavioral functioning. Right. And, you know, looking at those two pieces, and of course, as well with autism and as there's a spectrum of levels of functioning too.

Celine Saulnier, Ph.D. (09:52):
Yeah. And just to--for viewers who might not know the distinction there, the definition of intellectual disability, the diagnostic criteria are delays in both cognition and adaptive behavior. So IQ is your profile of abilities, whereas adaptive behavior are everyday practical skills, how we communicate, socialize, our motor abilities, our dressing, going out in the community. Everything we do is adaptive behavior. And those skills, they're delayed in intellectual disability when you're-- have cognitive delays, but usually to the same degree of delay. Whereas in autism, adaptive behaviors can be delayed even with high IQ. It's just people don't naturally acquire and apply these skills, which is why many autistic individuals fail to be independent in life. Because they, no one's explicitly taught them these skills and that's why it's so important.

Keith Sutton, Psy.D. (10:47):
Definitely. Okay, great. Oh, and the M - CHAT, what does that stand for?

Celine Saulnier, Ph.D. (10:54):
The MCHAT is the Modified Checklist for Autism and Toddlers. It's like a five-minute screener that parents complete yes or no questions saying, "Are there children at risk for autism?" It's not a diagnostic measure. It just screens for risk that then results in a referral for an evaluation. It's in its second edition and it's used worldwide. It's really wonderful.

Keith Sutton, Psy.D. (11:18):
Great. Yeah, and that's something I think is--I don't know how many folks are or clinicians are familiar with that, but autism can be diagnosed very young and the signs showing up. You know, sometimes I've had clients who are like, "Oh, is, are they too young to be able to be assessed for autism, a three or four or five-year-old or so on?" And it's like, "Oh, no, actually that happened."

Celine Saulnier, Ph.D. (11:39):
No, we can diagnose autism in infancy. Definitely by age two is when it should be diagnosed. Certainly in more complex and subtle presentations or when there's a lot of co-occurring, uh, things going on, it can get missed. But we should. It's neurodevelopmental. We should be catching it in the first few years of life. But the average age right now is still four plus, to eight years. And it's just too big of a gap between when we should be identifying and when we are.

Keith Sutton, Psy.D. (12:10):
And something you also talked about in the training, which I had not known about, was the eye movement tracking diagnostic tests to be able to diagnose autism. Could you speak to that for a moment?

Celine Saulnier, Ph.D. (12:24):
Sure. This is pretty much the bulk of the research that I was involved with at both Yale and Emory. So Amy Klin, Warren Jones, Cheryl Klayman, these are the principal investigators on all of this research. We're spanning three decades now where they looked at what autistic individuals look at in social scenes that is different from neurotypical development. So long story short, we know that neurotypical people focus on the eye region of the face and social scenes. And when something salient happens in a social scene, 80% of neurotypical people will look to that point in time at the same time, right? 'Cause it's meaningful. But in autism, not only are the eyes of the face not salient, mouth, body, and object detract attention. And then because of that, things in the environment detract attention and pull away from these social salient hotspots that the majority of people are focusing on and learn their social norms from.

Celine Saulnier, Ph.D. (13:33):
And so this divergence happens as early as six months, in infancy. And that divergence, the rate of divergence through the eye tracking technology is more predictive of future autism than any of the behavioral assessments that we perform, that are our observations. And that's called a biomarker. So the biomarker of eye tracking, this algorithm of what's socially salient, can now detect autism or help in the diagnosis. So the technology was FDA approved a couple years ago. Just between 16 and 30-month-old toddlers. But just this year in April, it was approved up to eight years of age. So now the biomarker can help us in conducting a diagnostic assessment. You have the individual watch videos for 10 minutes. And at the outset of 10 minutes, you get a downloaded protocol that says whether or not they have autism.

Celine Saulnier, Ph.D. (14:32):
And then you just have to do a little more assessments and not the comprehensive batteries that, you know, I talked for three hours.

Keith Sutton, Psy.D. (14:40):
Yeah. Yeah, exactly. Yeah. It's so great to be able to make that available to people and also, right, have something like that. I know I do a lot of work with ADHD and, you know, we wish there was some sort of, like, blood test or something like that would say yes or no. So it's so great that this has been developed for autism.

Celine Saulnier, Ph.D. (14:57):
And it's called Early Point Health. Okay, great. The Early Point is the technology and Early Point Health is the company. And I would recommend that anyone go on the website and learn more about it.

Keith Sutton, Psy.D. (15:09):
Great. Wonderful. And there was also some things that you talked about with genetic testing. Could you speak a little bit to that piece?

Celine Saulnier, Ph.D. (15:18):
There are so many different biomarkers being studied right now, whether it's blood tests, neuroimaging, eye tracking, you name it. But right now, there isn't a blood test for autism. However, autism's so highly genetic that if there is a mutation, which in about 30, maybe 30% of cases, you'll find a mutation in the individual, that the genes associated within that region of the mutation, they can be highly associated with autism to the point of actually being the cause of that person's autism. But there are a hundred to a thousand of these quote unquote candidate genes to the point where every day there are new discoveries. So today, we probably know about a handful more than we did last year. Mm. And there is another website called SFARI Gene, S-F A-R-I. So Simons Foundation Autism Research Initiative, that's the S-F-A-R-I.org

Celine Saulnier, Ph.D. (16:25):
And they have SFARI Gene where you can. If you find out your client has a genetic mutation, SHANK3, or a 16P11 deletion, you're like, "What is this? I know nothing about this, but I'm about to evaluate them for autism." You go on SFARI gene, type in 16P11 or SHANK3 or whatever, it will tell you all the articles and how many of them are showing findings that that gene is associated with autism. So then you can, with more confidence say, you know, this might be accounting for their autism.

Keith Sutton, Psy.D. (17:02):
Yeah, definitely.

Celine Saulnier, Ph.D. (17:03):
Certainly, there's a gene environment interaction. We still don't know about all of this. But, it really is, one of the most, if not the most, highly genetic, highly heritable of all childhood disorders.

Keith Sutton, Psy.D. (17:19):
Yeah. And, actually, that's one thing I was wondering if you could comment on, because there was not only, right, the genetics, if there's a direct, like, if one of the parents has autism, or other family members, there was also something you were mentioning about siblings and how a sibling who does not have autism but may have some autism characteristics, Kind of in the ballpark, but not actually autism with a-- who has a sibling who has autism. Can you talk a little bit about that piece?

Celine Saulnier, Ph.D. (17:50):
Of course. So starting with the general prevalence in the United States, autism is one in 31 children right now. So roughly 3% of the population has autism. If you have one child with autism and you're about to have another biological related child, that child's risk jumps from one in 31 to one in five. So now there are one in five chance of having autism. There's another one in five chance that that sibling will have shadow symptoms of autism, meaning they have some of the behaviors, but not enough to cross the threshold to get the diagnosis. But those symptoms still might be debilitating to that individual that might still require an invention of some sort, so it can be frustrating because they're following sub-threshold but still need support. And in the research world, that's called the broader autism phenotype. So many siblings can have that.

Celine Saulnier, Ph.D. (18:49):
And then many siblings, another one in 10, can have non-autism developmental delays. So they might have a speech delay, they might have a cognitive delay, but not the autism symptoms. So that's how highly genetic it is that these symptoms, these siblings are vulnerable in their development. And then we know if you have two with autism and now you're about to have a third, the rates go higher and higher. And now that the spectrum is so broad and many autistic individuals are growing up and being very functional adults, having their own relationships, having their own children, we don't know yet the rates, the risk, or the likelihood of autism of an autistic individual having their own autistic child. Right? We know it's higher, but we don't know what yet. And then the unaffected sibling having their own children, are at a higher risk as well, right?

Celine Saulnier, Ph.D. (19:47):
That would be the cousin. That would be the, yeah, trying to-

Keith Sutton, Psy.D. (19:57):
Sibling, the niece and nephew of the, would have a-

Celine Saulnier, Ph.D. (20:03):
But all of this is to be studied right now.

Keith Sutton, Psy.D. (20:06):
This is still in development, definitely. Well, so can you talk a little bit about the symptoms of autism and kind of the diagnosis, which might also--then I'd love to hear a little bit about those shadow symptoms. But yeah, could you share, about the symptoms of autism in the diagnosis?

Celine Saulnier, Ph.D. (20:25):
Sure. In our diagnostic system, which you know, the diagnostic and statistical manual, there are two hallmark areas of symptom expression. First and foremost, social communication and interaction, because it's a social disability or social differences where it's social communication, verbal and non-verbal. So this is where the eye contact, facial expressions, gesture use, body posture, spatial awareness, not only use of those things, but understanding of them in other people, which can be complex, right? And then the relationships, being able to sustain and maintain relationships. And this is from infants and toddlers all the way to adults, right? So that's broad. And then in addition to the social differences and vulnerabilities, you have the presence of what are called restricted interest repetitive behaviors or stereotype behaviors. These can be anything from your motor mannerisms of hand flapping, rocking back and forth, spinning, jumping, to fixation on topics, fixation on objects or parts of objects.

Celine Saulnier, Ph.D. (21:29):
It can be a need for sameness and routine, not liking transitions, very rule-governed, concrete thinking, black and white thinking. And then the sensory processing differences, hypersensitivities, hyposensitivities to input, and then seeking out sensory input. And, so it's collectively those two things, which now you can imagine that's very broad. No two autistic individuals present with the same symptom expression. And that's why there's this saying, if you've seen one person with autism, you've seen one person with autism. Which can be problematic because the diagnostic criteria doesn't say anything anymore about speech or cognitive ability. And you have anywhere from minimally to non-verbal individuals all the way to exceptionally verbal and extremely gifted intelligence, you know, and everything in between. So how can we call all of that autism? And so that can be problematic, and it's currently quite controversial, I think, in some parts of the field.

Keith Sutton, Psy.D. (22:37):
Yeah, one of the measures that you can,-- kind of brought my attention to is the, autism spectrum rating scale, which I think you were mentioning they just came out with the adult one, and I've given that to some of my adult clients. And it's just interesting as they kind of break down the different scales of socialization, social emotional reciprocity, atypical language, stereotypey, behavioral rigidity, sensory sensitivity, self-injurious behaviors, camouflaging, attention and anxiety, and just all these aspects, and as I've been giving them to some of my clients that are already pre-diagnosed with the spectrum, and looking at really kind of very different presentations, and which of those ones were higher or out of or, you know, in a significant range and so on.

Celine Saulnier, Ph.D. (23:26):
Yeah, and a shout-out to my friend and colleague, Sam Goldstein. He developed that measure. And as you're listing all those things out, you can see how keyed into the diagnostic criteria and the DSM the ASRS is. The childhood one always was, and the new adult version is as well. As much as it can be, because we're now trying to fit everyone into the diagnostic square box of the DSM. But we've defined the spectrum so broadly that now it's more nuanced, and we'll-- we can talk about females who do not meet the current criteria whatsoever. And so now, what does it say about these measures when we're trying to get the nuances, but the measures are kind of within the rigidity of our diagnostic criteria, because they're supposed to help us as clinicians, right, Make that accurate diagnosis.

Celine Saulnier, Ph.D. (24:17):
And so that leaves us to kind of using our clinical judgment of how much are, you know, do we take these results from one specific measure. And you've probably heard me say this ad nauseum, but there is no one measure that diagnoses autism. It's just us as clinicians. Same with ADHD or with anything, right? That's just our clinical impression. We're going on our knowledge and expertise, and we're gonna get it wrong sometimes.

Keith Sutton, Psy.D. (24:45):
Definitely. Yeah, and so maybe I could bring in some different ones. And again, it's always fine because this is--I've always said this is not my area of expertise, and I have worked with different clients with autism on the spectrum, been able to refer out and so on, but I feel like it's something that's presenting more and more. I don't know if it's just my practice or others' practices, but felt like I can't, I can no longer say I don't have expertise in this. I really need to dig in because it's something that's showing up in the office. And I also work with a lot of folks with ADHD and there's high comorbidity, for folks. And so one of the things that I've always thought of as the hallmark of autism is the theory of mind, uh, the ability to kind of think about what the other person is thinking or, and I think it's the I haven't given the ADOS, but somebody had described one of the ones where the person is looking at a picture of a girl looking in a shop at, like, a doll for sale or something like that, and then asking the person, "What is the girl thinking about?" And then rather than saying, "Oh, she's thinking about wanting that doll," they might point out something else, like, "Oh, she's thinking about the button or something that's on the ground" or whatever, you know, kind of focusing on an object or so on. Can you talk a little bit about this concept of the theory of mind?

Celine Saulnier, Ph.D. (26:07):
Yeah, this goes way back when it used to be considered the core cause of autism, right? This impaired perspective-taking-- the thinking and opinions and thoughts and beliefs of another person. That's so abstract. It's definitely something vulnerable in autism, but not the cause of it, right? That's the root cause. And what ends up happening, autism's so concrete and experiential, right? I know it because I experienced it, it's too abstract for me to think that your thoughts are different from mine. So if I think it, everyone must think it. If I believe it, everyone must believe it. And that's also that rule governed. And you can give these tests. I, the NEPSI has a subtest on theory of mind, you know, the decafs. There are a bunch of neuropsych tests out there that assess this, but you have someone pretty bright, they're gonna pass these tests, right?

Celine Saulnier, Ph.D. (27:10):
What are they thinking of? Because it's two-dimensional pictures. But in real life, it's far more nuanced than that. So you still see the vulnerabilities even when the scores on these tests can come up. So I tend to do more qualitative digging for the theory of mind. More in your clinical interviews and asking, you know, not only about their own thoughts and experiences, but throw in somebody else, you know, "What do you think your sister feels about that, or your best friend, or your partner, or your parents, you know, or their beliefs and just kind of get into that concrete nature." Also asking, many of these individuals have had failed experiences because of this vulnerability. That they maybe blurted out something that another person took as off-putting or insulting.

Celine Saulnier, Ph.D. (28:07):
That like, "Wow, why did you just say that?" But to them, it's just matter of fact. Like, "Oh, your dad died." "He's dead," right? Like, it's just matter of fact, pragmatic, not taking the perspective that that actually. They have emotions tied to that, and they're feeling something really powerful about that. And it's not a lack of empathy, it's a lack of understanding empathy, right? And that's a difference. And I think, unfortunately, many individuals can be misperceived as having a lack of empathy in that way. Yeah. And that's not the case at all.

Keith Sutton, Psy.D. (28:44):
Well, I've got a particular couple I work with and, and the partner, he'll say, like, "Well, I don't wanna understand. I don't..." You know, but then when he then takes the time and he's like, "Oh, you feel like that? Like, I wouldn't like that I'm making you feel that way." And then really able to connect with it, and understand, and actually, like, apologize and realize, like, oh, gosh, I don't wanna have that effect. That feels horrible. But it takes a while to get there.

Celine Saulnier, Ph.D. (29:10):
Explicitly lay that out sometimes that more so than you would ever figure you'd have to with a very bright adult, right? Like, why do I have to break it down to this concrete part for you to understand that? But that's the autism. And that's what people don't see. And, and that's why these therapies, like applied behavior analysis, are effective in, you know, from a research standpoint, because they're taking abstract concepts and breaking them down to very explicit components. Teaching that part and building it back up to the complex. And that's how the autism brain learns.

Keith Sutton, Psy.D. (29:50):
Yeah. And then, you know, another piece, again, and this might be back to the-- so one, the theory of mind is kind of, it's more like a symptom of the mental rigidity and the difficulty with the abstract thinking in that way and just assuming the other person is kind of thinking the way that I'm thinking. So the other piece around, you know, a focus on objects or a kid that is like really all about trains or I have one kid that came in recently and just the first session I was like, "Oh, where do you go to school?" And he gave me the exact address and I was like, "Oh." I was kind of wondering what neighborhood. And then I was like, "Okay." And kind of went up there and then, you know, parents were saying how he really loves the timetables of the buses and of the.

Keith Sutton, Psy.D. (30:39):
This a kid who is 11 years old. But I was like, "Okay, this I'm hearing some signs of autism there." And sometimes I've been told that some kids are like the, sometimes, hall monitor or very focused on the rules or people following rules or so on. Can you talk a little bit about those pieces, that kind of hyper-focused interest or something?

Celine Saulnier, Ph.D. (31:04):
Yeah, that divergence and development is what happens from birth. And this comes from the eye tracking research of my colleagues, that I was talking about where neurotypical babies, human beings come into the world just completely glued to the social. They're glued to their caregivers, they're glued to their family members, and then their friends, and their partners, and their own families. It's asocial trajectory throughout life. And everything that neurotypical people are monitoring in their environment is socially salient, right? We just are glued to what's going on socially in our world. So that's the neurotypical trajectory. In autism, the same intensity of learning is happening, but on non-social things. So from infancy, these details in the environment are picking up the attention, and that's like, oh, is it mechanical? Is it trains? Is it topic focused? It's picking up facts.

Celine Saulnier, Ph.D. (32:05):
It's all of the above, but it's non-social. And as you age, that gap widens. And so the eye tracking research has shown that by age two, like at 24 months of age, toddlers with autism are missing 10,000 opportunities for social learning in a two-hour period. And so now if we magnify that by the day, by the week, by the month, how many opportunities of social learning they're missing because that's not salient to them, but they are learning ad nauseum all these details and facts and everything that's still phenomenal. It's just not social. So they're missing what is necessary to navigate the social world, even at a modicum degree, right? Even at a basic level. And, so that divergence is usually persistent, but unless you're explicitly teaching the social norms, to focus on this.

Celine Saulnier, Ph.D. (33:11):
And it's not about teaching eye contact and people get that wrong. Because many autistic individuals have beautiful eye contact. They're still missing what's salient because they're not monitoring the whole social scene. It's more about why is this meaningful to everybody that is a learning experience? And a lot of that is picking up on the nuances. What does it mean when two people are having an argument and the facial expressions mean I'm confused or I'm getting angry or I'm overwhelmed. Or what does all that mean? And if females, it's like they're somewhere in between because they are deviating from the neurotypical norm. But they're not as detail object focused as the male norm. They can be really interested in characters and people and learning about things that are quasi-social. So they get missed because they look too good to be autistic.

Celine Saulnier, Ph.D. (34:15):
Yeah. But no one's realizing they're still falling far below the norm, and that causes anxiety and depression.

Keith Sutton, Psy.D. (34:22):
Yeah, definitely. Yeah, and actually, let's talk about the anxiety, because I think that's one of the big pieces too, is the social anxiety. That kid that I was working with, that was interested in the timetables, he was really struggling in school when there was unstructured time. When there was structured kind of group work or so on, that was okay, but when it was unstructured, it was really something that was anxiety provoking. And I forget if it was you or somewhere else that I was hearing somebody kind of using the term, emotional storm, that happens for folks. That's great. Yeah, with autism and just kind of like the overwhelm. Can you speak to that aspect of kind of dysregulation?

Celine Saulnier, Ph.D. (35:06):
You think might-

Keith Sutton, Psy.D. (35:07):
Might happen.

Celine Saulnier, Ph.D. (35:08):
Dysregulation is lifelong because you think about if you have these social vulnerabilities and you don't understand your social world, the minute you wake up in the morning, you're faced with demands socially in your own family and you walk out the door and now they're like compounded. And think of a child in a new school system with overstimulating physical environments, people demands, children, teachers, everything going, it's unpredictable. That's causing anxiety, anxiety, anxiety. Everyone's different in what causes their anxiety the most. Is it more about the demands coming at them? Is it the overstimulation, the understimulation, whatever? It could be all of the above. But it causes overwhelm and anxiety. So they're like in constant fight or flight. So they're either enduring the duress of the anxiety or they're fleeing and avoiding, which is your typical phobia, right? Your social phobia, your social anxiety.

Celine Saulniera, Ph.D. (36:05):
So it's almost like you can check off all the criteria for social anxiety if you have autism. A lot of the times. But you can have social anxiety and not autism.

Celine Saulnier, Ph.D. (36:16):
Right. That's completely different. That's, you know, as someone who has the foundational social competencies when they're regulated and calm and in a safe, trusted place, the autism vulnerabilities are gonna exist pervasively. So that anxiety, a lot of times, I actually diagnosed a 22-year-old female yesterday and was explaining to her and her mom that I'm more worried about the anxiety than I am about the autism symptoms, right? Like I'm giving you this label, but it's the anxiety that we need to address. But the anxiety's the byproduct of this social disability getting missed. So now we just have to address the anxiety from a different angle than your traditional anxiety therapies, right?

Keith Sutton, Psy.D. (37:00):
Rather than just doing exposure, looking at thoughts that are leading to the anxiety, actually looking to the social processes or kind of interpretation and understanding and relating socially.

Celine Saulnier, Ph.D. (37:14):
And then with any anxiety disorder, right, medication can be really beneficial as well. In addition to these therapeutic interventions and many autistic adults will tell you they can't walk out of their house without a medication for anxiety. Just to take the edge off to cope with this overwhelming social world.

Keith Sutton, Psy.D. (37:33):
And I was just actually listening to a training on autistic burnout. And just all that extra effort that's being put in to try to manage and deal and just being so draining.

Celine Saulnier, Ph.D. (37:46):
Exactly.

Keith Sutton, Psy.D. (37:47):
Yeah. Can you talk a little bit about the sensory sensitivities that some people with autism have?

Celine Saulnier, Ph.D. (37:54):
Of course. You know, I wrote my dissertation on the sensory processing differences in autism way back in the late '90s, early 2000s. And at the time, nobody was talking about this and it was not part of the diagnostic criteria. Sensory processing differences were more in ADHD and learning disabilities. And, that we had the sensory profile, that Winnie Dunn developed and is published by Pearson. Is the most prominent measure to assess all of these differences. And then it just became so widely researched in autism that-- and as we broaden the spectrum when we had more cognitively able individuals being able to articulate these sensory processing differences, that we realized how prevalent they were. So they finally made it into the DSM for autism criteria in 2013, but it doesn't mean that only autistic individuals have these sensory processing impairments.

Celine Saulnier, Ph.D. (38:55):
So you can have the hypersensitivities to sound, light, touch, food textures, tags and clothing, all that kind of stuff. But you can have the hyposensitivities too, that you don't really feel that input. So these are the kids that are, like, throwing themselves against walls. Wanting to be wrapped up in blankets, needing deep pressure. And, you can have a mix of all of these. There's no kind of recipe for it for one individual. And they can change over time. And what I think erroneously happened a lot is that when you saw these differences, it was behaviorally shaped out, right? Like, let's try to make you not that hypersensitive.

Keith Sutton, Psy.D. (39:43):
Yeah.

Celine Saulnier, Ph.D. (39:44):
Which can throw someone into trauma, right? That, like, but my body is physically, like, a volcano erupting. Your emotional storm that you were talking about. And now, I think we're having a better understanding of neurodiversity and acceptance that why don't we dim the lights or give the noise-canceling headphones and, you know, have soft clothing. And options for breaks and all of these different accommodations that will just let someone's nervous system become more regulated, so that then they can cope better. And, you know, we're making progress there in the workplace, in schools, and out in the community, but we still have progress to make there.

Keith Sutton, Psy.D. (40:32):
Yeah, definitely. And what is, kind of, the mechanisms with the sensory processing difficulties? And I'd love-- I of course see this in kids with ADHD too. And, you know, is it because there's not a inhibiting of the sensory input? Is there the way the sensory, information is received?

Celine Saulnier, Ph.D. (40:53):
Yeah. This, I think, is still ongoing research. And I-- From when I was really living in that space, for every study that you found some kind of finding. You found another study that showed no effect in that regard or a completely opposite effect. And I think that's why the sensory stuff got tossed out so much. Because it was such equivocal research. There was nothing coming out that was saying, "This is what's causing it." You can look at-- and they're doing so many physiological studies, you know? Increased sweat, heart rate, all of that. And then also the brain patterns. And that if you're looking in certain regions of the brain, are there differences? And yes, we're finding those. But again, yes, with an asterisk because there's nothing really definitive to my mind right now.

Keith Sutton, Psy.D. (41:50):
Sure. Got it.

Celine Saulnier, Ph.D. (41:50):
I would love to say that there is, so we can finally be like, "This is legitimate. Like, this is how you, you deal with it and help accommodate and treat it."

Keith Sutton, Psy.D. (42:00):
Yeah, with leading to it. Yeah.

Celine Saulnier, Ph.D. (42:02):
Um, but it's-- we're not there yet.

Keith Sutton, Psy.D. (42:04):
Still in process. Yeah. Okay. And how about the stereotyping behaviors? Or am I saying that right? Stereotypey?

Celine Saulnier , Ph.D. (42:11):
Oh, the stereotypical behaviors, stemming behaviors, people call them all these different things. The motor mannerisms. They're repetitive motor behaviors. Everyone has different ones, whether, you know, the hand flapping, what we call finger fanning, posturing. People can't see me doing this, but, you know, the atypical posturing of your hands, rocking back and forth, spinning, jumping, pacing, even bouncing. These are the repetitive behaviors. Again, they can serve different mechanisms. It can be when people are overstimulated, you see them. But look at ADHD. When someone's really excited, they'll jump and flap their hands. It's not specific to autism. When you see someone who's blind, they might rock back and forth. Mm. When you see someone with severe profound intellectual disability, they can have these behaviors. So they're not specific to autism, but they can be when someone's overwhelmed, when they're excited, when they're under-stimulated.

Celine Saulnier, Ph.D. (43:08):
And actually just trying to self-stimulate. They can be because of fear. It really is different for every individual. And without doing assessments to know that, there's no effective way to accommodate them because you could be doing the wrong thing.

Keith Sutton, Psy.D. (43:27):
Yeah, not understanding what the function is.

Celine Saulnier, Ph.D. (43:29):
Exactly.

Keith Sutton, Psy.D. (43:31):
Definitely. And, and so am I missing any of the main areas here as I've kind of gone through, as we've talked about kind of the theory of mind, about the rigidity, the focus on, you know, specific subjects or object, the sensory processing, the stimming?

Celine Saulnier, Ph.D. (43:51):
Yeah. Just thinking, because I was having this discussion yesterday with my client, that's why it comes to mind, we always reference autism as a social disability, that we're thinking it's the social vulnerabilities that are first and foremost. But if we go back prior to the DSM 5th Edition, autism had three categories of vulnerability. It was social, it was the restricted and repetitive behaviors, but communication was separate. And I think we forget about communication because so much of what someone's trying to communicate is with another person. It makes it social. But even think of a simple request, a child trying to, to point, to say, "I'm hungry. I want that. Help me. Give me. Stop." Any kind of basic expression of need is hard to do. Because it's part of the disability. And that even happens if someone has a high verbal IQ.

Celine Saulnier, Ph.D. (44:52):
They can still have difficulty communicating: communicating with speech, communicating with their gestures and their facial expressions, and especially communicating their emotions. They could have a vocabulary of a million words, and they still can't map on a simple sentence to express their internal emotional state. And that's so confusing to the outside world because they see the strengths, they don't see that communication vulnerability. And what happens is, a very amazing speech pathologist, said this, with my colleague at Yale, "Behavior equals communication." And I've used it ever since that if you can't communicate with your speech and your gestures and your facial expressions, you will communicate with your behavior. And it might come out in maladaptive ways, but that's still communication. And so these children and even adults will get erroneously interpreted as being a behavior problem. But they're really just trying to communicate.

Celine Saulnier, Ph.D. (45:54):
Yeah. And they, they've never been taught a more functional means to communicate, and they don't know how to do that on their, on their own.

Keith Sutton, Psy.D. (46:00):
Yeah. So needing that help.

Celine Saulnier, Ph.D. (46:02):
Right.

Keith Sutton, Psy.D. (46:03):
And can you talk-- I know we've only got a little bit, but about treatment and help for folks with autism. I know I was recently watching, a couple seasons ago, "Survivor", there was a woman who was autistic, and she talked about how when she was a child, her parents were told that she would never talk, she would not be able to function, and she was now had gone through graduate school and so on. But she also talked about, and she, actually seemed to do very well socially, although she talked about making alliances because she couldn't tell if other people were lying to her. And she had times where she got overwhelmed and actually had asked one of the other folks kind of preemptively to really give her a good squeeze and hug as she's kind of like going through that overwhelmed to help kind of ground.

Keith Sutton, Psy.D. (46:49):
And I've had other kids that I've worked with that got early intervention and were-- it was so slight at this point to the autism and how it was showing up because there was so much intervention. Yeah, can you share a little bit about that?

Celine Saulnier, Ph.D. (47:06):
I'm gonna qualify by saying I don't do treatment interventions. Okay. So I'm gonna talk about very broadly because we're talking about -

Keith Sutton, Psy.D. (47:13):
Sure.

Celine Saulnier, Ph.D. (47:14):
So many different levels of functioning. There are three levels of autism severity. One is mild, but still requires support and intervention. Two is moderate. And then three, that three would be reserved for your individuals who need twenty four seven lifelong care. The most severe and profoundly affected. That in really young kids, if I'm diagnosing an infant toddler, the intervention is parent coaching. You're teaching the parent who's the most important person in this individual's life how to provide the supports that they're not naturally acquiring. So how to stay engaged in the what's socially relevant. Because when they start to get distracted by their details and things, we want them to learn about those things, but we also wanna redirect their attention to be, learning what's socially salient. Like that social attention. And there's they're called NDBIs, naturalistic developmental behavioral interventions.

Celine Saulnier, Ph.D. (48:22):
And there are a whole bunch of them. So, you know, pivotal response treatment, early start Denver model. These are ones that people might have heard of. When you get to school-aged kids, preschool and older, if a child is at a level two or three, they probably need skills to be taught. And not just have their autism symptoms addressed. Skill acquisition, being taught how to speak, being taught concepts, being taught things, that's applied behavior analysis. That's why ABA is effective. That it's teaching through repetition, you know, hopefully natural reinforcement, but explicitly teaching the skill to increase the repertoire, to close the gaps and delays. And so that's effective. But then if a child has all the skills, and then some, but they still have the autism, now we're talking about teaching the the social norms.

Celine Saulnier, Ph.D. (49:24):
Right? So social skills groups can be really effective, because that's around where you're with same age peers, you're learning the social skill. Maybe you have the social skill, but you don't know how to apply it effectively. Sure. So how do you ask someone about themself? How do you sustain a conversation? How do you compromise when something's not your interest? How do you, you know, resolve conflicts? How do you even date? And how do you learn about sexuality and puberty and all that? Those are social skills groups. So that would be for this, the autism symptomatology, and that can be at any age. Right? All the way through adulthood. Then there can be the therapies for the associated symptoms. So the anxiety and the depression, right, the overwhelm. That's your traditional cognitive behavioral therapies. Your individual therapy can be very effective.

Celine Saulnier, Ph.D. (50:20):
It just takes a more directive approach. Because the therapist has to be very straightforward and explicit and concrete. And it's usually more of a coaching model, like we're gonna teach, practice, apply. A lot of role playing, a lot of, like, dos and don'ts, breaking down problems that happened. How do we resolve that? How can we fix it? And, and that can be effective. But then we get adaptive behavior, right? So everything that, that I love dearly, this gets missed all the time. This is the life coaching, the everyday real life skills coaching. Like the street smarts, the, you know, it, to our basic daily living skills to the more complex, like, every day, how do I even survive in the real world skills?

Keith Sutton, Psy.D. (51:11):
Yeah.

Celine Saulnier, Ph.D. (51:12):
And life coaches are now, like, everywhere. You know, you don't even have to be a licensed therapist to be a coach and to be a really effective coach. And then there's executive function coaches. Mm. Because everyone with ADHD, as you know, has executive functioning impairments, but many, many autistic individuals have very similar executive functioning impairments. And so the executive functioning coach can just help with planning and organization and breaking down tasks so that they're achievable and not overwhelming, and teaching how to have compensatory strategies like lists and timers and all that. So I'm throwing a ton of-



Keith Sutton, Psy.D. (51:51):
No. Yeah. It's a big question. It's a big, big one. It's a big question. Well, and I think that, you know, to the compensatory strategies, that also kind of gets into the aspects of, right, there's, there's accommodation, right? How do we change the environment? Yeah. There's been a lot of conversation around neurodiversity. Yeah. And then other. When the person does have to compensate or, you know, and that kind of bleeds over into, you know, usually, kind of in a negative way, the camouflaging or the masking of symptoms, and trying to find ways to be able to kind of either, camouflage and pretend symptoms, or pretend kind of behaviors that non-neurotypical folks have or masking and kind of, you know, kind of trying to hide or diminish the neurodivergent symptoms.

Celine Saulnier, Ph.D. (52:38):
Yeah, let's talk about that, because that's a hot topic right now. And for, for listeners who might not know what these concepts are, camouflaging, we all do camouflaging. Think of when you go into a new social situation, you scan the room and try to, like, body posture and try to figure out, "How am I supposed to act here?" That's camouflaging, right? We're always gonna borrow, to a degree, someone's speech, someone's posture, someone's behavior, someone's whatever. Masking is slightly different. Masking's the idea of hiding behaviors that you think are different. So someone flaps their hands, they know that they've probably been teased for that, they put their hands in their pocket, and they're really struggling not to move their hands. Or not talk incessantly about their topic of interest. That's masking. Autistic individuals mask and camouflage to a debilitating degree. So they're not doing it just to get by, like we do in new situations.

Celine Saulnier, Ph.D. (53:37):
They are doing it constantly. They might be constantly rehearsing scripts in their head before they go into a conversational context. They are studying TV shows, characters, books, or maybe even real people, it could be a sibling, anything, to a point that it's, like, exhausting. And then they have burnout, and the research is unequivocal in showing the more you mask and camouflage, the higher the anxiety, depression, suicidality. So they become maladaptive coping strategies. So what happens with the therapy then is to teach more effective ways to cope - uh-huh. Um, rather than relying on those strategies to such an intense degree. And there's one measure called the camouflaging autistic traits questionnaire, the CAT cue, developed by Hull and colleagues. And it starts at 16 and goes through adulthood, and I use that all the time. But just to qualify, non-autistic people can camouflage and mask to debilitating degrees.

Celine Saulnier, Ph.D. (54:46):
You're going to see it a lot in social anxiety. Yeah.

Celine Saulnier, Ph.D. (54:50):
Can read books on ADHD and masking, and trauma can cause masking to a debilitating degree. So just because someone comes high on the CATQ doesn't mean they have autism. But it's just another piece of information to be helpful.

Keith Sutton, Psy.D. (55:04):
Yeah. Well, it sounds like it's also, right, a spectrum of masking. Like, you might have to mask, you know, getting frustrated with a boss or something like that. You know, holding that back at work. But yeah, with autism, again, it's like there's, there's so much work to be managing everything. Well, thank you so much. This is really great. I really appreciate the training I went to the guidance in our conversation. And I think this is just an important subject for clinicians to be thinking about, hearing about, and become more aware and really helping clients that maybe got missed or helping with early intervention. So, this is really great. Thank you so much for your time.

Celine Saulnier, Ph.D. (55:44):
It's been my pleasure. Thank you for having me.

Keith Sutton, Psy.D. (55:46):
Okay, take care. Bye-bye.

Celine Saulnier, Ph.D. (55:48):
Bye.

Keith Sutton, Psy.D. (55:49):
Thank you for joining us today. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults with our licensed experienced therapists, in-person in the Bay Area or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships, and low-fee treatment through our nonprofit, Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstiteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC's website at sf-bacc.org. BACC is a 501 nonprofit, so all donations are tax deductible. Also, we really appreciate your feedback.

​Keith Sutton, Psy.D. (56:55):
If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.

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