Ask the Expert- Summer 2013

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Geraldine Dawson, PhD joined Duke University Medical Center as Professor in the Department of Psychiatry and Behavioral Sciences on August 1, 2013. Dr. Dawson was a joint hire of Psychiatry and Behavioral Sciences and the Duke Institute for Brain Sciences. She also holds secondary appointments in the Department of Pediatrics and the Department of Psychology & Neuroscience.

Dr. Dawson came to us from Autism Speaks, the world's leading autism science and advocacy organization, where she served as Chief Scientific Officer for the past six years. Prior to this, Dr. Dawson built a world class clinical and research program at the University of Washington. She is an expert in early childhood mental health and developmental disorders, including autism. We invite you to learn about Dr. Dawson's work and her shared vision for promoting children’s overall social and emotional health at Duke below.
 

What sparked your interest in researching autism and developmental disorders?

How has our understanding of autism and developmental disorders changed over time?

To what do you attribute the increased prevalence of autism?

In your opinion, what are the most influential recent advances in autism research?

What is your vision for the future of autism treatment at Duke?

Tell us about the collaborative effort to establish a Center for Children’s Social and Emotional Health here at Duke.

How will Duke become a global leader in training the next generation of autism researchers and clinicians?

What most excites you about joining Duke?


What sparked your interest in researching autism and developmental disorders?

My interest in autism began in graduate school when I was training as a clinical psychologist. My very first case was a child with autism. At that time, autism was still a rare condition. What struck me was that we had very little understanding of what caused autism: how is it that a child has difficulty forming social relationships and communicating? By understanding this, we would not only be able to help individuals with autism, but we would also learn more about how we all form relationships. Intellectually, this was a compelling topic, but it also really captured my heart. We had very little by way of treatment to help this boy develop social relationships, or support for his parents. I felt that this was an area where I could devote myself and hopefully make a difference.

How has our understanding of autism and developmental disorders changed over time?

Over the last few decades we have developed a much better understanding of the causes of autism. We now know that genetic factors play a significant role. We are also exploring environmental risk factors that could interact with genetics to increase one’s risk of developing autism. We now understand that autism is not one condition but many different conditions with many different causes and variable expression. This requires varied treatment approaches to be able to personalize treatments to address the specific needs of each individual, rather than a one size fits all treatment plan. Research is focusing on identifying biomarkers that can help us to better recognize the many forms of autism and provide the right treatment for each person.

In this same time period, the prevalence of autism has increased by more than 1,000%, and this has compelled us to think about how we address what is now a huge public health challenge. We need to train professionals and teachers, and help families on a much larger scale in order to address the needs of people with autism throughout the lifespan. Because we can now identify infants at risk for autism, we can begin intervention during infancy. We are also learning much more about autism from a lifespan perspective: from childhood to adolescence through adulthood. This broadened lifespan perspective is essential because people spend the majority of their lives as adults.

Finally, while we still have much to learn, we know much more about the underlying biology of autism. For example, neuroimaging studies have revealed how differences in brain functioning affect social behavior and language and, from a developmental perspective, how the brain becomes wired differently in individuals with autism. Based on the work in genetics and animal models, we have also learned about differences in brain function at the molecular level which allows us, for the first time, to consider drug targets that could address core autism symptoms, such as difficulties with social functioning. At the same time, new treatment approaches, especially those based on technology, can encourage the unique talents and abilities of people with autism. In this regard, we are learning much from individuals with autism themselves. Some individuals with minimal verbal skills have authored books and attended college, using alternative means of communication.

To what do you attribute the increased prevalence of autism?

We do know that broadening the definition of autism, better awareness, and access to services have all contributed to the increased prevalence. However, epidemiological studies suggest that these factors alone do not account for this upsurge. Researchers are increasingly studying environmental risk factors that might contribute to autism, especially those affecting the prenatal period. The field of epigenetics, which examines how the environment influences how genes are turned off and on, is going to play an important role in our understanding of autism.

In your opinion, what are the most influential recent advances in autism research?

We have made significant advancements in understanding the causes of autism over the last few decades, including learning more about its genetic architecture. We now know that there are hundreds of genes that contribute to autism risk, and these genes appear to be influencing a handful of signaling pathways in the brain. By identifying these signaling pathways, we can begin to develop potential drug targets that could lessen disabling symptoms. Animal models have provided insights into the underlying biology of autism and allowed us to test different treatments. Studies have demonstrated that reversibility of symptoms in animal models is possible, even in adult animals. This has fundamentally reshaped the way we think, not only about neuroplasticity—the brain’s ability to form new neural connections—but about new directions for treatments.

The ability to identify autism very early in life has been a significant breakthrough. Research over the past year has shown that it is possible to identify structural and functional changes in the brain early on in infants who are at risk for autism. For the first time, we have begun to think about possible prevention strategies - to intervene during infancy before the full syndrome is present so that disabling symptoms can be reduced or prevented. We have also shown that when a child is provided with early intensive behavioral intervention this not only has a significant impact on the child’s cognitive ability, social and language skills, but it actually normalizes brain function. This tells us that autism is not a static condition, but rather a dynamic developmental condition. Neuroplasticity makes early treatment all the more effective. People with autism can benefit from treatment throughout their lifetimes. Studies with adults with autism have demonstrated changes in the brain as a result of treatment.

Another significant advancement is the understanding that autism is not just a brain disorder but that it affects the whole body. We have learned that autism can affect the immune and GI systems, sleep, and metabolic functions. When we address these medical conditions, behavioral and psychosocial treatment outcomes improve. Many more clinicians are beginning to use a holistic approach, addressing both behavioral and physical health.

What is your vision for the future of autism treatment at Duke?

To begin with, it truly takes a village to provide the best care for an individual with autism. The goal is to help each person with autism reach his or her optimal potential and lead a meaningful, productive, and satisfying life. That means that a close partnership between the University and the community (people with autism, families, schools, community practitioners, and government) is essential. Autism treatment is a multi-disciplinary team effort across various specialties. I am very excited to help bring together the incredible expertise that exists at Duke across disciplines and departments to develop a personalized, comprehensive approach to care. My vision is to facilitate a treatment program that is family-centered and seamless, with continuity of care that addresses both behavioral and physical health throughout the lifespan. Because the treatment center will be closely integrated with the autism research program, families will benefit from the latest treatments that are available and will be invited to become partners with us in research aimed at developing even more effective treatments. Technology will play an important role because it can help determine the right treatment for the right individual, coordinate care and communication across providers, provide information and resources to families and providers, and track what treatments are most effective.
 

Tell us about the collaborative effort to establish a Center for Children’s Social and Emotional Health here at Duke.

The vision that a number of us have at Duke is to consider autism within a broader mission of promoting children’s overall social and emotional health, with a focus on the toddler-preschool age. Children with autism share many of the same challenges as children with other mental health conditions such as ADHD and anxiety disorders; there is much overlap. We hope to be able to identify these challenges in very young children so that intervention can address not only autism symptoms but also these other challenges very early in life. It is important that we don’t think of a child as a diagnosis but that we look at the unique challenges of each child that need to be addressed. By bringing together expertise at Duke across a broad range of mental and physical health conditions, we hope to promote social and emotional health, beginning with toddlers and preschool age children.

How will Duke become a global leader in training the next generation of autism researchers and clinicians?

We want to be involved in education and training across Duke Medicine and Duke University. Our goal is to provide clinical and research training for students at all levels – undergraduate, graduate students, medical students, interns, residents and fellows, and post-doctoral fellows. In addition, there is really a great and urgent need to be able to build global professional and research capacity to address the increasing number of people with autism. Our vision is for Duke to become a partner with the community to train and engage professionals locally, as well as training professionals in both the clinical and research realms on a global scale. Duke’s Global Health Institute’s and Duke Medicine’s existing partnerships in Asia, Africa, and other parts of the world will help facilitate a global effort toward improving the lives of people with autism worldwide. New technologies will allow us to scale up these training efforts to reach people in remote and low resource communities.

What most excites you about joining Duke?

Duke is world-renowned for its medical care and its cutting edge research, particularly in the area of brain sciences and interdisciplinary collaboration. I can’t think of a better place, for both resources and the wide range of expertise, to establish a world class autism research and treatment center. The Departments of Psychiatry and Pediatrics and the Duke Institute for Brain Sciences offer tremendous talent and resources. The Center for Developmental Epidemiology in the Department of Psychiatry is involved in a wide range of basic science and clinical science focused on developmental neuroscience, which will provide an opportunity to create an autism research program that focuses on early detection and treatment. I am very excited to have the opportunity to collaborate with colleagues across Duke Medicine and Duke University to create a program that provides coordinated clinical care for families, improves care through innovative research, and builds capacity in the community through training.