#330 – 自闭症、ADHD与焦虑：理解自闭症发病率上升的原因，以及对儿童每种病症进行多学科诊断与治疗的方法 | Trenna Sutcliffe, M.D.

很多环境因素被认为与此有关。

There is a lot of environmental factors that have been implicated.

但我想说的是，先退一步，简单聊聊自闭症的成因、遗传和环境因素，把这件事说清楚。

But what I wanna say is just to take a step back first, just kind of talk about the cause of autism, the genetics, and the environmental piece, just to make it really clear.

“自闭症”这个词描述的是一组症状群。

The word autism describes a constellation of symptoms.

自闭症的成因有很多很多种。

There are many, many causes for autism.

它并不是由单一原因引起的。

There isn't a single cause.

自闭症的成因非常复杂，实际上我们的疑问比答案还多。

What causes autism is very complex, and we actually have more questions than answers.

不过，人们认为这有点像“十次打击”模型，意思是虽然我们不确定具体是不是十次，但核心想法是，需要多次打击。

It's felt though that it is like a 10 hit model, meaning we don't know that the number's 10, but the idea that there's multiple

两次打击模型。

a two hit model.

这里面涉及的因素很多，感觉就像是基因、基因、基因，环境、环境、环境。

There's many factors involved, and it's almost felt like it's gene, gene, gene, environment, environment, environment.

现在又加上表观遗传学、表观遗传学、表观遗传学。

And then now it's like epigenetics, epigenetics, epigenetics.

所以是多重的打击，而且打击的顺序和时间也被认为非常重要。

And so it's multiple hits and the order of the hits and the timing of the hits are also felt to be very important.

我们先从遗传部分开始吧。

Let's start with the genetic piece.

我们播客之前请过不少嘉宾。

We've had a number of folks on the podcast over time.

所以听众们可能已经熟悉我们说的遗传度是什么意思。

So the listeners are probably familiar with what we mean by the heritability of something.

但也许为了那些需要复习一下的朋友，我们可以这样讲：一个疾病的遗传度，不管是抑郁症、精神分裂症还是双相情感障碍，很大程度上是通过同卵双胞胎出生后分开抚养、在完全不同的环境中长大来确定的。

But maybe just for folks that need to brush up on that, we would talk about the heritability of a condition, whether it be depression, whether it be schizophrenia, whether it be bipolar disorder, is largely determined by you have identical twins separated at birth, raised in completely different environments.

他们两人患上同一种精神疾病的可能性实际上有多大？

What is effectively the probability that they're both gonna come down with the same psychiatric condition?

这既是不幸也是幸运，因为当我们不知道具体是哪些基因，或者基因数量太多、情况非常复杂时，这是我们能了解遗传度最纯粹的方法。

And that's unfortunately, fortunately, that's the purest way we can get at what the genetic heritability is of something when you don't know what the genes are or when there are so many genes and it's very complicated.

我记得自闭症的遗传度相当高。

And my recollection is that the heritability of autism is quite high.

具体数字我记不清了。

I don't remember the number.

你能给我讲讲吗？

Can you enlighten me?

根据当时使用的定义不同，大概在百分之七十到百分之九十八之间，但通常都超过百分之九十。

It'll be anywhere from seventy percent to ninety eight percent, depending again on the definitions used at the time, but it's well over ninety percent.

哇。

Wow.

我没想到会这么高。

I didn't know it was that high.

对。

Yeah.

我还以为是百分之八十多，不过那也已经很高了。

Thought it was in the eighties, which is still very high.

我是不是也记得没错，自闭症的遗传率比DSM里其他任何疾病都要高？

Am I also correct in my recollection that the heritability of autism is higher than it is for any other condition in the DSM?

我觉得是的。

I believe so.

对。

Yeah.

对。

Yeah.

也就是说，即使是精神分裂症、双相情感障碍、抑郁症这些我们知道有很强遗传因素的疾病。

In other words, even schizophrenia, even bipolar, even depression and things that we know have very strong genetic components.

确实如此。

It is.

它们的遗传率都没有自闭症那么高。

None are as high as it is for autism.

对。

Correct.

这肯定有遗传因素。

There's definite genetic component to this.

但我可以说，这不是单一基因的问题吧？

But may I say, so it's not one gene?

对。

Yeah.

我正想说这个。

I was just gonna say.

所以我们得让大家明白。

So let's make sure people understand.

对。

Yeah.

不是单一基因的问题。

It is not one gene.

是多个基因。

It is multiple genes.

所以任何自闭症患者，他们的多个基因都发生了改变。

So anybody with autism, they have multiple genes that have been changed.

所以每个自闭症患者体内都有多个基因变异。

So there's multiple genetic changes in anybody with autism.

而且，每个自闭症患者，他们发生改变的基因群可能都不一样。

And the other thing is every person who has autism, they probably have a different group of genes that have been changed.

实际上有数百个，有些人说甚至多达上千个基因与自闭症相关。

It's actually hundreds, and some people say up to like a thousand genes have been associated

与自闭症相关。

with autism.

也许我可以这样解释，如果你不喜欢这个类比，请纠正我，我觉得这有点像癌症，但有一个根本的区别。

Maybe a way that I would explain this, and please correct me if you don't like this analogy, I liken it to cancer with a fundamental difference.

所以，先听我说完，你可以随时反驳我。

So, hear me out for a second and feel free to shoot this down.

癌症主要是体细胞突变，而不是生殖细胞突变。

Cancer is mostly about somatic mutations and not germline mutations.

也就是说，大多数时候，一个人得癌症，并不是因为出生时带的基因。

Meaning, most of the time when a person gets cancer, it is not based on genes that they were born with.

而是因为那些原本正常的基因，后来获得了突变，变成了突变状态。

It's based on genes that were at one point normal that have since acquired mutations in their mutated state.

它们不再正常工作了。

They no longer function normally.

这个人就得了癌症。

The person develops cancer.

所以，这让我这个类比变得复杂了，因为只有大约百分之五的癌症来自生殖细胞突变，而与自闭症相关的基因确实是生殖细胞突变。

So, this complicates my analogy because only about five percent of cancers arrive from germline mutations, whereas the genes that are implicated in autism are indeed germline.

你是天生就带着这些基因的。

You're born with them.

不过，我真正想说的是，把癌症的体细胞突变和自闭症的生殖细胞突变进行比较。

However, the point I want to really make is comparing the somatic mutations of cancer to the germline mutations of autism.

我想说的是，你见过一位患有乳腺癌的女性，你就只是见过一位患有乳腺癌的女性。

And the point I'm trying to make is that when you've met a woman with breast cancer, you've met a woman with breast cancer.

你很难找到两个看起来完全一样的乳腺癌患者。

You're not going to find too many women that look the same with breast cancer.

这也是为什么基因疗法对大多数癌症都没能奏效。

And that's really why gene therapy hasn't panned out for most cancers.

因为说一个人得了乳腺癌，只能告诉你一些基本信息。

Because to say that a person has breast cancer tells you some stuff.

你可以再深入一点，比如她是雌激素阳性、孕激素阳性、HER2阳性。

You could dig a little deeper and say, Well, it's estrogen positive, it's progesterone positive, it's HER2nu positive.

但即便如此，为什么她们的反应不是都一样呢？

But still, why wouldn't they all respond the same?

那是因为她们背后有很多不同的基因变化。

Well, it's because they have many different underlying genetic changes.

而且，她们的肿瘤在免疫反应方面也完全不同。

Furthermore, they have completely different immune responses in terms of what their tumor looks like.

所以，我自己是这么想的：如果你看到一百个自闭症孩子，咱们随便挑一个比较保守的数字，我们会说这其中有百分之八十五到九十是遗传的。

And so, the way I try to think about it myself is if you see a 100 kids with autism and let's just pick a number that's somewhat conservative, we would say that that's eighty five to ninety percent heritable.

这仅仅意味着他们每个人的潜在基因是遗传来的，但这些孩子之间的基因可能毫无关联。

It simply means that the underlying genes for each of them were inherited but they might have nothing to do with each other across all of those children.

就像我们说所有得乳腺癌的女性都有导致乳腺癌的获得性突变，但这些突变可能各不相同。

Just as we would say all of the women who have breast cancer have acquired mutations that gave them breast cancer but they could all be very different.

我同意。

I agree.

再说，我也可以挑这个比喻的毛病，但我觉得这样想可能更容易理解，因为多基因的东西确实很难搞明白，尤其是当我们还不知道所有相关基因的时候。

Again, I could poke holes in that analogy but I think that's maybe an easier way to think about it because polygenic things are harder to wrap our heads around, especially when we don't know what all the genes are.

对。

Yeah.

所以我们并不清楚所有基因。

So we don't know all the genes.

我们知道确实存在遗传因素。

We know that there is this genetic component.

就像每个自闭症孩子都有自己独特的基因指纹一样。

It's like each child with autism has a different fingerprint with their genetic makeup.

所以确实存在这些基因变化，但我提到的有些影响因素是环境方面的。

And so there's these genetic changes, but some of the hits I mentioned are environmental.

有研究表明，母亲的压力、污染、母亲的饮食、父母的年龄等。

So there is research to show maternal stress, pollution, maternal diet, parental age.

这些因素也与自闭症有关。

These things also are associated with autism.

而且，这样的因素还有很多。

And again, there's a long list.

所以，相关的因素有很多，但没有哪一个单独能解释自闭症。

So there's a long list of things that are associated, but none of them alone, each one alone is not the key to autism.

关键是它们的组合。

It's the combination.

我还在纠结的是，让我们再举一个大家都能理解的例子。

The thing I'm still struggling with is, let's take another example that I think we can all point reasonably at.

五十年前，二型糖尿病的发病率大概在百分之一点五到百分之二之间。

Fifty years ago, the incidence of type two diabetes was in the ballpark of one point five to two percent.

当时美国有百分之一点五到百分之二的人患有二型糖尿病。

One and a half to two percent of people in The United States had type two diabetes.

现在，天哪，我好久没看了，但已经超过百分之十了。

Today we're God, haven't looked in a while, but it's over ten percent.

我说的是明确的二型糖尿病。

And I'm talking clear type two diabetes.

不是那种处于糖尿病前期灰色地带的情况。

I'm not talking about in the gray area of pre type two diabetes.

所以，可以说在一代人的时间里，这种病的发病率增加了五到七倍。

So, let's just say we've had a five to seven fold increase in a condition over the course of one generation.

那么问题就来了，环境诱因是什么？

So then the question of what are the environmental triggers?

如果说是基因变化导致的，那很难解释，因为基因不可能在这么短的时间内发生这么大的改变。

It would be very difficult to explain that just genetically that there's been some genetic change.

我们可能有遗传易感性，也可能有遗传表现，但关键在于，一定有某些东西发生了变化。

We might have genetic susceptibilities, we might have genetic manifestations, but the thing of it, something must have changed.

我觉得大多数人会把矛头指向我们的饮食环境，认为那是推动这一变化的主要因素，因为五十年来饮食环境的变化是巨大的。

And I think most people would point to our food environment as the leading thing that has driven that change because the change in the food environment in fifty years is dramatic.

所以当我们用同样的逻辑来看自闭症时，我们是否看到这些环境诱因在过去二十年或二十五年里发生了足够大的变化，以至于可以说，二十五年前出生的孩子就有同样的遗传倾向。

So when we apply the same logic to autism, do we see big enough changes in these environmental triggers, even just over the last twenty years or twenty five years, to say, okay, twenty five years ago kids were born with the same genetic predisposition.

除非我们相信有更多人配对结合，产生了更多的基因组合，从而比以前更多地表现出这种表型，否则不可能有那么多遗传漂变。

There can't be that much genetic drift unless we believe we are seeing more people pair together to combine four genes or genetic combinations that are producing this phenotype more than we saw before.

这个我们可以回头再谈。

We can come back to that.

我很想听听你对这个问题的看法。

I'd love to hear your thoughts on that.

但咱们先把这个放一边。

But let's put that aside for a moment.

如果我们说正在发生的表观遗传变化是由环境中的某些东西触发的，而且我们谈到父亲年龄在上升，母亲压力在增加，母亲营养在变差，环境毒素、微塑料到处都是。

If we're saying that whatever epigenetic change is happening is triggered by something in the environment and we're talking about if paternal age is going up, if maternal stress is going up, if maternal nutrition is getting worse, if environmental toxins, microplastics are all over.

大家都在讨论这些事情。

Everybody's talking about those things.

重金属什么的，不管是什么。

Heavy metals, whatever it is.

我想更深入地了解一下，听听你对这些因素如何影响它的看法。

I would love to go into a little bit more detail and get your thoughts on how those things are changing it.

当然，我们得谈谈疫苗。

We have to talk about vaccines of course.

我想这里会有一部分人，他们很自然地会想，嘿，那疫苗呢？

There's going to be a subset of people here I think who understandably would think, hey, what about vaccines?

我们给孩子的接种方式不是改变了吗？

Haven't we changed the way we vaccinate kids?

这有没有参与其中呢？

Is that participating in it?

你提到过这是一种在子宫内的遗传状况。

Now, you mentioned that this is an in utero genetic condition.

如果是这样的话，那儿童疫苗的责任可能比一些人想象的要小。

If that's the case, then childhood vaccines might be less responsible than some might think.

但我很想听听你对这些事情的看法。

But I'd just like to hear you riff on all of this stuff.

因为在讨论该怎么做之前，我觉得还是有很多人在问我们是怎么走到这一步的。

Because before we get into the what to do, I still think there's a lot of people asking how did we get here?

我希望我能知道所有答案。

I wish I had all the answers.

但我不知道。

I don't.

我觉得这个问题很复杂。

I think it's complex.

你提到的饮食、污染、毒素暴露这些方面都有变化。

There have been changes in you talk about diet, pollution, toxin exposure.

我觉得这只是其中的一部分。

I think that's one piece of it.

这只是一部分。

It is one piece.

关于表观遗传学，你知道的，可能是表观遗传变化，这里给大家澄清一下，DNA序列并没有改变。

With epigenetics, as you know, it can be epigenetic changes, which just to clarify for everybody, the DNA sequence is not changed.

而是DNA上的标签，或者叫组蛋白的蛋白质发生变化，这些变化最终导致基因表达的改变。

It's about tags on the DNA that can change the expression of genes or proteins called histones that are changed that end up resulting in changed gene expression.

但改变的基因表达实际上也可以遗传，或者代代相传。

But the changed gene expression can actually be inherited or passed through generations as well.

对。

Yeah.

我正要

Was gonna

问你这个问题。

ask you about that.

我们知道表观基因组确实会遗传吗？

Do we know that to be a fact that the epigenome is being transmitted?

我觉得这有争议。

I think it's controversial.

我觉得这有争议，但确实有人这么想。

I think it's controversial, but there is some thought about that.

就是说，祖父母在胎儿时期接触过吸烟、毒素、饮食变化，这些暴露可能会改变父母作为胎儿时的生殖细胞的甲基化，然后那个生殖细胞后来发育成患有自闭症的孩子。

About the idea of the germ cells in a fetus, in a grandparent being exposed to smoking, toxins, changes in food, how that grandparent exposure can actually change methylation in the germ cells of a parent who's a fetus, who then that germ cell goes on to be a child with autism.

我不知道我说清楚没有。

I don't know if that made sense.

有点让人困惑。

Was sort of confusing.

这对我来说

It makes

非常清楚，因为我日夜都在想这个问题。

a ton of sense to me because I think about this problem night and day.

我想确保听众明白，首先，这还没有被证实。

I do want to make sure the listeners understand that first of all, this is not established.

完全不是。

Not at all.

我想确保他们明白我们在说什么。

And I wanna make sure they understand what we're saying.

那我们再解释一遍。

So let's explain it one more time.

我们有四种构成DNA的东西。

We have these four things that make up DNA.

就是C、G、A和T，这就是密码。

Your C, G, A and T and that is the code.

这是生命的密码。

That is the code of life.

但在这些碱基的骨架上，你可以加上一些甲基基团，就是一个小碳原子带着三个氢原子，这叫做表观遗传学。

But on the backbone of those things, you can put little methyl groups, which is just a little carbon with three hydrogens and that's called epigenetics.

顺便说一下，我们出生时，整个表观基因组，也就是基因组的背面，都布满了甲基基团。

And by the way, we're all born with methylated groups all over our epigenome, back of the genome.

随着生命的发展，我们知道这种情况会改变。

Over life, know that changes.

所以我们知道，仅仅是衰老就会改变甲基化。

So we know that simply aging changes methylation.

但我们相信，个体之间的甲基化差异，是对你刚才提到的那些事情的反应。

But we believe that there is differential methylation in individuals in response to all the things that you've talked about.

而且我们知道，甲基化控制基因表达。

And we know that methylation controls gene expression.

事实上，甲基化可能是控制不同组织中基因表达差异的最重要因素。

In fact, methylation is probably the single most important thing that controls differential gene expression in different tissues.

所以关键问题是，如果你有一种甲基化模式，你能把它传给你的胎儿吗？

So the question, the jugular question is, if you have a methylation pattern, can you pass that on to your fetus?

而你刚才说的更了不起，就是那个孩子长大后，会不会把这种甲基化模式传给他的胎儿？

And what you said a minute ago is even more remarkable, which is would that child when they develop pass that methylation pattern on to their fetus?

到那时，甲基化表观遗传学就开始变成遗传了，对吧？

At that point, methylation epigenetics would start to become genetic, right?

它开始成为生殖细胞系的一部分。

It starts to become a part of the germline.

所以，我的意思是，顺便说一句，在我的书里，这是一个可以回答的问题。

So, I mean this is an answerable question by the way in my book.

当我想到那些我们十年内应该知道答案的事情时，我会把这件事列入其中，因为我认为我们将有足够的纵向数据来解答这个问题。

When I think of things that we should know the answer to in a decade, I'm going to put this in the list of things that we should know the answer to just based on the fact that we will have enough longitudinal data, I think, to be able to get at this.

我不知道你是否和我一样乐观。

I don't know if you're as optimistic as me.

是的，我很乐观。

I am.

关键是我们确实知道环境会影响甲基化和表观遗传。

The key thing is that we do know the environment impacts the methylation and the epigenetics.

所以这就是跨代传递的概念。

So it's the idea of it crossing generations.

这个概念是指，生殖细胞中的甲基化因为父母或祖父母的某种环境暴露而改变或变化。

It's the idea of the methylation in a germ cell is altered or changed because of some sort of environmental exposure in, again, that parent or grandparent.

所以从这个角度看，孩子现在容易受到两方面的影响。

And so in that sense, the child is now susceptible to two things.

一方面是从父母双方继承的生殖细胞，另一方面是胎儿时期，由于你提到的那些其他因素而发生的甲基化影响，对吗？

The germline that they inherit from both parents and as a fetus, the methylation impact that occurs as a result of any of these other factors you've discussed?

对。

Yeah.

哪些人在最密切地研究这个问题？

Who are the people that are studying this most closely?

这属于遗传学家的研究范围吗？

Is this in the purview of the geneticists?

这属于流行病学家的研究范围吗？

Is this in the purview of the epidemiologists?

哪些人最致力于这方面的研究？

Who are the people that are most working at this?

因为再说一遍，一般来说，我一直认为，在不了解流行病因果本质的情况下就去研究它，是非常不明智的。

Because again, as a general rule, I always think that it's very foolhardy to work on a problem, an epidemic without understanding the causal nature of the epidemic.

我举个例子，比如心脏病治疗。

I use the example of heart therapy.

它彻底改变了艾滋病的面貌。

Changed the face of HIV forever.

这是传染病医学最伟大的成功故事之一。

One of the greatest success stories of infectious disease medicine.

但这一切都建立在对病因的理解之上。

But it was all predicated on understanding what the cause was.

如果你不明白HIV是在破坏CD4细胞，

You didn't understand that HIV was destroying CD4 cells.

你根本不可能有机会开发出那种疗法。

You didn't have a prayer of developing that therapy.

你会不会担心，三十年后，每三个孩子里就有一个会受到影响？

And do you ever worry that what's to say this isn't gonna get to be one in three kids in thirty years?

而且，像你这样的人够不够多，能不能帮助父母、家庭和孩子应对这种情况？

And are there enough people like you that are going to be able to help parents and help families and help children with that?

我不想危言耸听，但我担心的是，当我们可能面临一场流行病时，我们对病因却不太清楚。

I don't wanna sound alarmist, but I worry when we have an epidemic potentially and we don't have a great sense of causality.

这说得太深刻了。

That's profound.

我在想好几件事。

And I'm thinking about a number of different things.

第一，我在想，因为你刚才提到这个“三分之一”的比例。

One, I'm thinking about because you're talking about this one and three.

我只是随口一提，就是说，嘿。

And I'm just throwing that out as, hey.

如果这个趋势继续下去怎么办？

What if this trend continues?

对吧？

Right?

不过，其中一个问题是我们如何定义这种状况。

And so one of the issues though is how we define the condition.

问题就在这儿。

That's the thing.

所以这个因素还是存在的。

So there is still that.

不过我相信，这里面有遗传和环境的作用，还有我们如何进化，以及这种表型。

Although I believe that there is this piece with genetics and the environment and how we are evolving, and there's this phenotype.

这种表型表现为社交沟通能力的差异，以及重复行为和兴趣受限。

This phenotype where there's differences in social communication skills and repetitive behaviors of restricted interests.

这种表型本身也是一个很大的谱系。

This phenotype, which is on a huge spectrum as well.

我得确认一下，这就是关键。

I should make sure this is the thing.

当我们谈论这些数字，比如三十六分之一，而且这个数字还在不断上升时，这不仅仅是指那些非语言自闭症的孩子。

When we are talking about these numbers, like one in thirty six and this number continues to increase, it's not just the kids who are, like, nonverbal autism.

而是这个非常广泛的表型在增加。

It's this really wide phenotype is increasing.

所以重要的是我们要弄清楚为什么这种表型在增加，以及我们应该或不应该对此做些什么。

And so it is important we understand the cause of why this phenotype is increasing and then what should we or should not be doing about that.

关于频率或患病率的变化，你知道些什么？我们挑一个子集，比如那些非语言或严重受损的孩子，连我或家长都能诊断出来的那种。

What do you know about the change in the frequency or the prevalence of, let's pick one subset of that, which is the nonverbal or child that is so impaired that I could diagnose them or a parent could diagnose them.

我们是否知道，尽管诊断标准变了，过去二十五年里这个数字是否基本保持不变？

Do we know if that has remained relatively constant over the last twenty five years despite the change in diagnostic criteria?

我相信那个数字也在增加。

I believe there's an increase in that number as well.

但公布出来的那些数字，那些非常惊人的数字，实际上描述的是整个谱系。

But the numbers that are put out there, the really profound numbers actually describe the entire spectrum.

而且它们并没有细分到谱系的不同部分。

And they don't actually subdivide into the different parts of the spectrum.

你大概有个数吗？

Do you have a ballpark idea?

所以如果过去二十年自闭症的整体诊断增加了五倍，那更严重的部分增加了百分之五十，还是百分之百？

So if the overall diagnosis of autism is increased fivefold in the last twenty years, Has that more severe part gone up by fifty percent, by a hundred percent?

我是说，你觉得是怎么回事，或者你知道是怎么回事吗？

I mean, what do you think it is or what do you know it is?

我们把自闭症谱系分成三个等级：一级、二级、三级。

So we subdivide autism spectrum into three buckets, level one, level two, level three.

所以那些受损更严重的孩子会归到三级，他们需要非常大量的支持。

So the more significantly impaired children would fall into level three where they require very substantial support.

真正针对这些子等级的研究其实很少。

There are very few research studies that actually look into these sub buckets.

说实话，我不确定临床医生在识别这些子等级的孩子方面总是做得很好。

And I have to be honest, I'm not sure clinicians are always great at identifying kids in the sub buckets either.

就像你和我现在讨论的这个非常具体的类型，按理说应该很容易识别，但有些三级的孩子，有时候会被归到二级，这取决于他们看的是哪个医生。

Like, you and I are talking about a very specific profile that should be very obvious to identify, but there's other kids in sub bucket three that are sometimes put in sub bucket two depending on what clinician they see.

我猜，三级并不等于2013年之前被诊断为自闭症的所有孩子。

And I'm gonna guess that sub bucket three is not the totality of the children that were called autistic prior to 2013.

这个假设靠谱吗？

Is that a safe assumption?

是的。

Yes.

就算数据存在，听起来好像也没有，我们也不能直接说，DSM IV 里自闭症的患病率是多少，跟现在的自闭症谱系三级相比怎么样。

You can't even say, assuming the data existed and it sounds like they don't, we can't just say, what was the prevalence of autism in the DSM IV and how does it compare to ASD sub three today?

那样比较根本没有意义。

That wouldn't even be a meaningful comparison.

我不确定有没有人研究过这个，但确实，我不

I'm not sure if anyone's looked into it but yeah, I don't

知道有没有。但就算有人研究过，也不是一回事。

know if But even if they did, it wouldn't be apples to apples.

确实不是。

It's not.

好。

Okay.

顺便说一下，他们当初把阿斯伯格综合征、非典型自闭症、自闭症障碍合并成一个自闭症谱系，其实挺有争议的，因为临床医生在判断这些分类时做得真的很差。

By the way, one of the reasons they actually went from the Asperger syndrome, PDD NOS, autistic disorder because that was actually quite controversial when they actually decided to put all three of those things under one umbrella called autism spectrum, was because clinicians did a really poor job of deciding

你属于哪个类别。

Which bucket you were in.

你属于哪个类别。

Which bucket you were in.

所以你会有一个孩子，一个临床医生会说是阿斯伯格综合征，另一个会说是自闭症障碍，还有一个会说是广泛性发育障碍未特定型。

So you would have a child, and one clinician would call it Asperger's syndrome, another person would call it autistic disorder, another person would call it PDD NOS.

所以他们决定，好吧，与其用这三个名称，不如都归到自闭症谱系下。

So they decided, okay, rather than having these three names, let's put it all under autism spectrum.

然后他们把它归到自闭症谱系下，接着又分了一级、二级、三级。

So then they put it under autism spectrum, then they have level one, level two, level three.

但我还是觉得临床医生有时候还是会纠结，因为有些地方有点重叠。

But I would still say that clinicians still struggle sometimes where there is a little bit of overlap.

不是总是那么清楚。

It's not always clear.

现在，如果你回到DSM IV时代，正如你提到的，医生们很难决定该把孩子归到哪个类别，作为一个旁观者，我的第一个问题是，这对治疗和资源分配有影响吗？

Now, if you go back to DSM IV when, as you mentioned, physicians are struggling to know which of these buckets to put them into, as an outsider looking in, my first question is, does it matter in terms of treatment and resources?

在结果和支持方面，影响更大吗？

Does it matter more in terms of outcomes and support?

人们关心这个肯定是有原因的。

There must be a reason why people cared about that.

换句话说，如果你在2000年有一个孩子，一个医生说这个孩子有阿斯伯格综合征。

In other words, if you had a child in the year 2000 who one clinician said, This kid has Asperger's syndrome.

另一个人说，不，他们是自闭症。

And another person said, No, they're autistic.

那这会不会对他们得到的支持类型产生实质性的影响？

Was that going to make a material difference in the type of support that they got?

最重要的是，他们会成为什么样的人？

And most importantly, the type of person they were going to turn into?

比如，他们能否充分发挥自己的潜能和独特的能力？

Like, were they going to reach their full potential in their differential capacity?

所以，在资源方面确实有影响。

So it did make a difference with respect to resources.

患有阿斯伯格综合征的孩子常常得不到支持，或者支持不被覆盖。

Children with Asperger's syndrome frequently did not get support or support covered.

好的。

Okay.

你需要被诊断为自闭症障碍才能获得支持。

You needed autistic disorder to get support.

那PDD NOS呢？

And what about PDD NOS?

是垃圾箱吗？

Waste bucket?

不需要，对。

Didn't need Yeah.

人们不知道该怎么处理那个。

People didn't know what to do with that.

所以如果把所有东西都归到自闭症下面，那就好像，好吧。

So if by putting everything under autism, then it's like, okay.

如果你有自闭症，就应该得到服务。

If you have autism, you should receive services.

那是一个工具。

It was a tool.

这个标签是用来理解和获取资源的工具。

The label's a tool to understand and get resources.

现在我们有了一级、二级、三级。

Now we have level one, level two, level three now.

一级是说需要支持。

Level one is it says requires support.

二级是需要大量支持。

Level two is requires substantial support.

三级是需要非常大量的支持。

Level three is require very substantial support.

我担心的是，当一个孩子是一级时，他们不一定能得到所需的支持，因为他们有很多优点。

My concern is that, again, when a child is level one, they don't always get the support they need because they have so many strengths.

所以一级的孩子通常认知能力不错。

So kids in level one, frequently, have good cognitive skills.

他们的语言能力也很强。

They have a lot of language skills.

他们在社交技能上有些困难，有时在执行功能和应对能力上也会遇到问题。

They struggle with some social skills, and they may have some difficulties with executive functioning and coping skills at times.

但同样，这被认为是轻度的，很多这样的孩子得不到支持。

But, again, it's considered mild, and a lot of those kids don't get support.

我觉得这很可惜，因为他们恰恰是那种只要得到一点指导，比如如何应对压力、如何适应变化、如何练习社交技能，就能很好地回应干预的孩子。

And I think that's unfortunate because they also are the kids that respond to intervention so well if they get a little coaching on how do you cope with distress, how do you cope with change, how do you practice some social skills.

不是说他们必须改变。

Not that they have to change.

我们不需要改变他们的一切，只是给他们一点支持，让他们能更好地适应社区生活。

We don't need to change everything about them, but giving them a little bit of support about how to, again, be adaptive in a community.

对这群孩子来说，这样的支持能起到很大的作用，但因为他们被标记为一级，所以常常得不到支持。

Giving that support goes a long way with that group, but frequently they don't get the support because they're called level one.

帮我了解一下，七八十年代那些孩子的自然发展情况是怎样的。

Help me understand the natural history of those kids back in the seventies and eighties.

在七八十年代，我们小时候，没人会特别在意那些孩子，对吧？

Back in the seventies and eighties when you and I were kids, nobody thought anything of those kids, right?

他们当然不会被贴上自闭症的标签。

Certainly weren't going get labeled with autism.

他们当然也不会出现在学校的项目里，去接受社交技能和沟通技能方面的帮助。

They certainly weren't going to show up with in school programs to help them with their social skills and with their communication skills.

就像你指出的，他们在智力上没有问题，所以他们在学校不会遇到什么困难。

As you pointed out, they're intellectually not impaired, so it's not like they're going to struggle in school.

但很明显，他们确实在某些方面有困难。

But there's clearly something that they're struggling with.

显然，这方面没有研究过，但我非常好奇，想听听你的经验和判断。

Obviously, this hasn't been studied, but I'm very curious based on your experience and your judgment.

那些人是不是就选择了那些不需要和人打交道，但依然可以做有挑战性的认知工作的职业呢？

Are those people that just went on to pick careers where they didn't have to interact with people but they could still do challenging cognitive work?

他们后来的情况是怎样的？

What was the natural history of them?

显然有很多这样的人。

There are clearly a lot of them.

确实有。

There are.

这样的人很多。

There are a lot of them.

我觉得他们找到了适合自己的路。

And I think they found a path that made sense to them.

他们显然清楚自己的优势，这些优势可能在于记忆力、注重细节、遵守黑白分明的规则。

They obviously learned what their strengths were, and their strengths may have been around memory, detail oriented, following rules that are black and white.

他们可能在某些领域有很强的认知能力，这些领域不太涉及推理和社交，而是更具体、更实在。

They may have had really wonderful cognitive skills in certain areas that were less around inferring and social skills and more concrete.

是的，虽然没有研究能确切证明这一点，但我猜他们过着幸福、成功的生活。

And, yeah, we don't have studies to say this for sure, but my guess is they have lived happy, successful lives.

他们中的很多人，有些人，在做自己喜欢或热衷的事情。

A lot of them, some of them, doing things that they enjoy doing or passionate about.

他们可能找到了办法，不去参加大型社交场合，但世界上有很多职业很适合他们。

They probably have found ways to not engage in large social settings, but there's a lot of careers out there that are a good match.

而且他们也有恋爱关系和婚姻。

And they also have relationships and marriages.

这一点我想特别强调。

I just wanna emphasize that.

自闭症患者也会结婚。

People with autism get married.

我觉得现在听我们节目的这些人里，肯定有成千上万，甚至好几万这样的人。

I just think there's zero chance that there aren't thousands, if not tens of thousands of these people listening to us right now.

因为他们现在已经是成年人了，我就在想，他们听到这些内容的时候，会不会觉得特别有共鸣。

Because they're adults today and I wonder if they're listening to some of this and they're saying this resonates.

我懂那种感觉。

I get that.

我小时候对这些东西特别着迷。

When I was a kid, I was hyper focused on this stuff.

我对很多事情都不太感兴趣。

I wasn't interested in a whole bunch of stuff.

我跟其他孩子互动起来有点困难，诸如此类的。

It was a little harder for me to interact with other kids and things like that.

但我还是找到了自己的路，现在也走到了今天。

And yet I found my path and here I am today.

所以我经常跟家长聊这个，因为我做儿童评估。

So I talk to parents all the time about this because I evaluate children.

我评估孩子是否有自闭症或多动症。

I evaluate children for autism or ADHD.

很多时候，在我评估孩子、跟家庭建立关系的过程中，家长会说，天哪。

And very often when I'm evaluating the child, at some point, while I develop this relationship with the family, the parents say, gosh.

我孩子身上有太多我的影子了。

So much of my child is in me.

你描述我孩子的优点和挑战时，我看到了我自己，这正是我小时候经历过的。

As you are describing my child and my child's strengths and challenges, and I see me, and this is exactly what I went through when I was young.

然后他们会分享那段日子有多难，他们会说，天哪。

And then they share how hard it was, and they say, gosh.

没人理解我，或者因为被误解而难过，或者以为是我的错。

No one understood me, or I felt bad because I was misunderstood, or I thought it was my fault.

我不够努力。

I didn't try hard enough.

所以我得说，对成年人来说，知道这不是他们的错，而是他们天生的特质，这能让他们感到被认可。

So I have to say it can be validating for an adult to learn that it wasn't their fault, and this is part of their wiring.

有很多很多家长问我，我现在应该去做评估吗？

I have many, many parents who ask me, should I go get assessed now?

你怎么回答？

What do you say?

我会问一些问题。

I ask questions.

我觉得信息就是力量。

I think information is power.

我觉得让他们考虑这件事是好的，不管他们最后是否真的去做评估。

I think it's good for them to be thinking about it, whether or not they go on to actually get assessed.

对于自闭症这块，他们通常不会去做。

With the autism piece, often they don't.

对于多动症这块，他们往往会去做，因为他们意识到自己的多动症特质确实影响了他们的工作表现和职业成功。

With the ADHD piece, they often do because they realize actually their ADHD traits are impacting their function and success of their job.

所以有时候他们会真的去找精神科医生做评估。

So sometimes they will actually go to a psychiatrist to get an assessment.

但我确实会跟他们分享遗传和家族史方面的信息。

But I do share with them the genetics and the family history.

那我怎么说呢？

So what do I say?

我会先肯定他们的感受。

I validate.

我会说，是的。

I say, yes.

你告诉我，从小到大，你有很多特质，今天我们会把这些特质归入这些诊断之一。

You're telling me that growing up, you had many traits that today we would classify under one of these diagnoses.

你说得对。

You're right.

这是有可能的，因为这些情况确实会在家族中遗传，而且有很强的遗传因素。

It is possible because these things do run-in families, and there is a highly genetic component.

而且我觉得有时候，仅仅是这样的对话本身就有治疗作用，因为那个人感到被认可，并且有了那个时刻。

And I think sometimes just that conversation can be therapeutic itself in that someone feeling validated and they have that moment.

就像，好吧。

Like, okay.

这解释了很多。

This explains a lot.

然后他们也会感觉很好，因为他们会想，好吧。

And then they can feel good as well because they're like, okay.

这解释了很多事情。

This explains a lot.

然后我继续往前走。

And I've gone on.

现在我有自己的家庭，生活很多方面都过得不错。

And I currently have my family, and I'm doing well in many parts of my life.

但这也能帮助他们理解，比如，啊，现在我明白了为什么有时候我在工作或和配偶相处时会遇到这些挑战。

But it helps them also understand, like, ah, but now I understand why sometimes I do have these challenges at work or with my spouse.

有时候换个角度看问题很有意思，当你能够用不同的视角看待自己的挑战时，可能会帮助一个人真正开始思考，好吧。

It's interesting just sometimes having a perspective where now you can see your challenges through a different lens sometimes helps a person just to actually now think about, okay.

现在我可以调整或者理解那些触发点，或者反思下次该怎么回应。

Now I can adjust or understand the triggers or can reflect to think about how do I wanna respond the next time.

所以我觉得，这些信息确实能给人力量。

So I think again that information's empowering.

即使他们不去看心理医生或者做其他事情，仅仅开始了解这些信息本身就有帮助。

Even if they don't ever go to therapy or do anything else, just actually starting to become informed about it can help.

对。

Yeah.

而且我猜这对他们教育孩子也很有帮助，因为他们能看到，嘿，我的孩子有这个诊断，这在一定程度上解释了，你知道，我们可能遇到的挑战等等。

And I would imagine it helps them a lot with their child because they're seeing both, hey, my child has this diagnosis that now partially explains, you know, the challenges we might be having, etcetera.

但同时，因为我自己经历过，我能理解那个孩子，这让你成为更好的父母。

But at the same time, because I can empathize with that child if I've experienced it, it makes you a better parent.

所以你说的这些都很有力地支持了扩大诊断范围的做法。

So everything you said makes a great case for widening the diagnostic envelope.

因为如果我们回到四十年前，那时候的诊断范围非常非常窄。

Because if we go back forty years, we had this narrow, narrow envelope.

换句话说，我们当时的测试特异性非常高，但敏感性非常低。

In other words, we had a test that had very, very high specificity but very low sensitivity.

你会漏掉很多人。

You were missing a lot of people.

但可以肯定的是，你不会出现误诊的情况。

But you didn't get any false positives, that's for sure.

你不会过度诊断。

You didn't overpathologize.

以前，如果一个人被诊断为自闭症，那他就真的是自闭症。

When someone was autistic, they were really autistic.

现在，问题反过来了。

Today, have the opposite problem.

我们现在的诊断标准，可以说是高灵敏度、低特异性。

We have a high sensitivity, low specificity test, sort of.

这是我编的。

I'm making that up.

不过，拿癌症诊断来打个比方，大家就明白了。

But you know, just to bring it to cancer diagnostics for people.

所以现在，任何有自闭症的人都应该被诊断出来，但这样一来，我们就在扩大这个定义的范围。

So now anybody who's autistic should get diagnosed, but then we're stretching what that means.

而且说实话，现在很多被诊断出来的人，可能即使没有支持，也能过得很好。

And a lot of the people getting diagnosed today, frankly, maybe without any support would go on to do just fine.

你担心当DSM六出来的时候，它的范围会更广，我们可能会开始听到有人说，嘿，我们是不是在过度病理化这个？

Do you worry that when the DSM six comes out, it could have a wider envelope and we could start to get to a point where someone might say, hey, are we over pathologizing this?

是的。

Yes.

我们是不是到了那种地步，正常到底意味着什么？

And are we getting to a point where, well, what does normal even mean anymore?

我非常同意这一点。

I agree with that so much.

所以我其实经常问这个问题。

So I actually ask that question all the time.

我确实在想，每次一个孩子有这些特征中的几个，我们是不是每次都在给那些只是有点不同的人下诊断。

I do wonder every time a child has a few of these traits, whether or not we're coming up with the diagnosis every time someone is just a little bit different.

而不是意识到神经多样性，我们每个人都不一样，我们总是要给它一个名字。

And rather than realizing there is neurodiversity, we're all different, we have to give a name to it all the time.

这是一个有趣的辩论，你会听到不同的观点。

It's an interesting debate, and you will have you'll hear different perspectives.

我是说，名字能帮我们获得资源、帮助别人，但我也担心我们非得给每样东西都起个名字。

I mean, the name gives us a way to get resources and help people, but I also concerned that we have to give everything a name.

我其实在想，下一版DSM会不会反而往回退一步，风向会不会稍微转一转。

I actually wonder in the next DSM whether we'll end up taking a step back, whether the pendulum will swing a little bit.

那什么时候会这样呢？

And when does that do?

我不知道。

I don't know.

第三版和第四版之间，第四版和第五版之间，隔了多久？

What was the gap between three and four and four and five?

十五年？

Fifteen years?

我觉得大概二十年吧。

I would say a couple decades.

那可能真的还要再等十年。

It could literally be another decade.

有可能。

Can be.

但一级，我们刚才说的是自闭症一级。

But level one, we were talking about level one autism.

所以我担心，一级自闭症的孩子可能实际上属于几个不同的诊断类别。

So I'm concerned that the kids in level one autism might actually be part of several different diagnostic buckets.

那些被认定为一级自闭症的孩子，他们看一个医生，那个医生可能会诊断为自闭症。

Children who identify with level one autism, they see one clinician, that person may diagnose autism.

他们看第二个医生，那个医生可能会诊断为多动症加焦虑症。

They see a second clinician, that person may diagnose ADHD plus anxiety.

他们甚至不称之为自闭症。

They don't even call it autism.

我在诊所里经常看到这种情况。

I see this all the time in my clinic.

有些孩子来诊所之前，可能已经看过三个其他医生了。

I have kids who come to clinic, and they may see three other clinicians before they saw me.

都是很优秀的临床医生，标准很高，是专家，但一级自闭症的界限确实很模糊，你会听到不同的诊断。

Really great clinicians, high standards, experts, but there's a lot of blurry lines with the level one autism, and you will hear different diagnoses.

所以回到你对未来DSM的看法，我在想我们该怎么处理一级自闭症。

So back to your thoughts around future DSMs, I wonder how we're gonna address level one autism.

它是同一种病吗？

Is it the same condition?

那个类别里到底有多少种不同的病？

How many different conditions are in that bucket?

你看，对我来说，我会这么想：我希望到我们不得不做决定的时候，能有足够的数据。

See, to me, the way I would think about that is, I would hope that by the time we have to make that decision, we would have enough data.

数据会回答最重要的问题，那就是我们如何影响结果。

And the data would ask the most important question, which is how are we impacting outcomes?

换句话说，当我们扩大诊断范围，把这种ASD一级放进去，那就为更多资源打开了大门。

In other words, when we widen the diagnostic envelope and said that we're going to now have this ASD class one in here, that opened the door for more resources.

这意味着更多孩子在学校能有相应的项目。

That meant more kids had programs at school.

什么是IEP？

What's a IEP?

IEP。

IEP.

IEP。

IEP.

更多的孩子在学校有IEP。

More kids have IEPs at school.

那代表什么？

What does that stand for?

个别化教育计划。

Individual Education plan.

教育计划。

Education plan.

归根结底，我们想知道的是，这些孩子是否真的变得更好了？

And at the end of the day, what we want to know is, are those kids doing better?

如果答案是肯定的，那可能就值得保留。

And if the answer is yes, then it's probably worth keeping.

如果答案是这根本没起什么作用，我们只是给家长制造了一堆焦虑，也许确实没起作用。

If the answer is, that didn't make a darn bit of difference, all we did was create a bunch of anxiety for the parents and maybe it didn't.

再说一次，我不知道该怎么回答这个问题，但我希望比我聪明得多的人能从这个角度去思考，因为我们不能忘记这一切的根本目的。

Now again, I don't know how one goes about answering that but I would hope that somebody a lot smarter than me is thinking about it through that lens because we can't lose sight of the whole purpose of this.

就像医学上任何诊断的目的都应该是影响结果。

Like the purpose of a diagnosis anywhere in medicine should be to impact an outcome.

为了诊断而诊断并不是一个特别有价值的工具，除非你是流行病学家。

A diagnosis for the sake of a diagnosis is not a particularly valuable tool unless you're an epidemiologist.

但即使在那里，也应该本着如何让人们变得更好的精神。

But even there, it should be all in the spirit of how are we making people better.

我同意。

I agree.

所以这就是为什么，我再次同意，一级的孩子应该接受服务。

And that's why, again, I agree that the kids in level one should be receiving services.

不然的话，给出这个诊断还有什么意义呢？

Otherwise, what's the point of giving the diagnosis?

对。

Yeah.

所以他们应该得到服务。

So they should be receiving services.

如果我们非得给它换个名字，那又有什么关系呢？

And if we need to call it something by a different name, who cares?

只要它能让孩子得到服务，比什么都不做强，那就行了。

As long as it gets the service that makes them better off than they would have been had they received no service.

在我们深入讨论你具体怎么治疗之前，我想先把诊断这部分说完。你能谈谈这些情况的重叠吗？

Before we get into more of the details about what you do specifically treatment wise, I want to finish one other bit of the diagnosis piece, which is can you talk a little bit about the overlap?

你刚才提到了一点，关于自闭症、多动症和焦虑症。

You just did it sort of a second ago about ASD, ADHD and anxiety.

它们重叠的频率有多高？

How often do they overlap?

那些维恩图是什么样的？

What do those Venn diagrams look like?

我先说一下，我们诊断孩子有焦虑症，有这样一个类别。

I'm gonna start off by saying we diagnose anxiety in kids and there's that bucket.

有很多孩子明显属于焦虑类别，符合标准，这很容易看出来。

And there's many kids who just clearly fall in the anxiety bucket and meet criteria, and it's really clear to see that.

有些孩子有多动症，明显符合多动症的诊断标准，属于那个类别。

There are kids who have ADHD and clearly meet diagnostic criteria for ADHD and fall in that bucket.

还有一些孩子明显属于自闭症类别。

And then there are kids who clearly fall into the autism bucket.

我先重点讲自闭症类别。

I'm gonna focus on the autism bucket first.

我们常说，大约一半的自闭症孩子也同时有多动症的诊断。

So we say that about half of kids with autism also have a diagnosis of ADHD.

看数据的话，不同报告显示的比例从百分之四十到百分之七十不等，但我们通常说大约一半的自闭症孩子确实同时有多动症的诊断。

If you look at the numbers, they're anywhere from you can find reports for anywhere from, like, forty percent to seventy percent of kids, but we say about half of kids with autism actually do have a diagnosis of autism.

有趣的是，在DSM-5之前，也就是2013年之前，我们是不允许同时给这两个诊断的。

Interestingly, before the DSM five, before twenty thirteen, we were not allowed to give both those diagnoses together.

所以它们是互斥的。

So they were mutually exclusive.

如果孩子有自闭症，我们就不会给ADHD的诊断。

If a child had autism, we did not give a diagnosis of ADHD.

所以从2013年开始，我们开始同时诊断，而且我们经常这么做。

So starting in 2013, we did, and we give it a lot.

所以很多自闭症孩子也有ADHD的症状，我们就会给这个诊断。

So a lot of children with autism have ADHD symptoms as well, and we give that diagnosis.

大约40%的自闭症孩子也有焦虑问题。

And about forty percent of kids with autism also have anxiety.

这很合理，如果你想想大脑中涉及的相关区域。

This makes sense when you think about the parts of the brain involved.

说到ADHD，我们主要考虑的是执行功能方面的能力。

When you think about ADHD, we're thinking about executive functioning skills.

我们说的是前额叶。

We're thinking about prefrontal lobes.

说到焦虑，就涉及杏仁核。

And when you're thinking about anxiety, you're thinking about the amygdala.

而且，对自闭症儿童进行神经影像学研究时，我们发现大脑很多区域都参与其中，特别是额叶、杏仁核，还有小脑和颞叶。

And then when people have done neuroimaging studies in kids with autism, we find there's many areas of the brain involved, but in particular, frontal lobes, the amygdala, as well as the cerebellum, temporal lobes.

大脑有很多很多区域都参与其中。

There's many, many areas of the brain involved.

但自闭症儿童确实在执行功能和焦虑方面存在挑战，尽管这些并不属于诊断标准。

But kids with autism do have challenges with executive functioning and anxiety, although those are not part of the diagnostic criteria.

所以这些是伴随症状、伴随特征、伴随诊断。

So those are associated symptoms, associated traits, associated diagnoses.

所以它们是共病，不是核心诊断标准的一部分，但有很多重叠。

So they're comorbidities, not part of the core diagnostic criteria, but there's a lot of overlap.

如果百分之五十的自闭症儿童有ADHD，百分之四十还伴有焦虑诊断。

If fifty percent of them have ADHD and forty percent of them also carry a diagnosis of anxiety.

那有没有一个百分比，是那些同时有这三种情况的人？

Is there a percent of those that are overlapped and have all three?

是的。

Yeah.

很多人三种都有。

A lot of them have all three.

这个具体数字我不太清楚。

I don't know the exact number for that one.

好的。

Okay.

事情是这样的。

This is the thing.

这些孩子，他们表现出自闭症的核心特征，同时还有执行功能方面的挑战，并且很焦虑。

These kids, they present with the core features of autism along with the executive functioning challenges and are anxious.

好的。

Okay.

那现在关于有多动症和焦虑症的孩子，我们能说些什么呢？

So now what can we say about kids with ADHD and anxiety?

这两者重叠的情况是怎样的？

What's that overlap?

有多动症和焦虑症的孩子，他们患自闭症的比例没那么高。

Kids who have ADHD and anxiety, their numbers towards autism are not as high.

所以有很多多动症的孩子并没有被诊断为自闭症。

So there are a lot more kids with ADHD who are not diagnosed with autism.

但多动症和焦虑症之间有很多重叠。

But there's a lot of overlap between ADHD and anxiety.

所以我常跟家长说，多动症经常有个“伴侣”。

So ADHD frequently has a partner is what I tell families.

如果你有多动症，你往往要么有焦虑症，要么有其他情绪问题，要么有学习差异。

If you have ADHD, you often have either anxiety or some other mood challenges or you have learning differences.

所以多动症的孩子经常伴有学习障碍，或者有对立行为。

So learning disabilities are frequently present in kids with ADHD, or you have oppositional behaviors.

所以患有多动症的孩子通常还会伴随第二种情况。

So there's often a second condition present in kids with ADHD.

再多讲讲对立行为倾向吧。

Say more about oppositional behavioral tendencies.

有一种诊断叫做对立违抗性障碍。

So there is a diagnosis out there called oppositional defiant disorder.

对于年幼的孩子，当我看到对立行为时，我不会轻易或频繁地使用这个诊断。

That is a diagnosis that I don't use quickly or often in young kids when I see oppositional behaviors.

我个人的做法是，我会说这个孩子有对立行为。

This is my personal approach is that I will say I see a child with oppositional behaviors.

那是什么意思呢？

What does that mean?

意思就是爱争辩、不守规矩、不听话、撒谎。

Mean someone who argues, doesn't follow rules, disobeys, lies.

对于有这类行为的孩子，我想先弄清楚背后的原因，然后再下结论说他们患有对立违抗性障碍。

So kids with these types of behaviors, I wanna understand the why before I jump into saying that they have oppositional defiant disorder.

严格来说，他们可能符合诊断标准。

Technically, maybe they meet the criteria.

再说一次，那只是这个名称的清单式标准。

Again, it's a checklist criteria for that name.

但对我来说，这个名称没什么用。

But to me, that name doesn't help me.

它只是个名字而已。

It's just a name.

就像，好吧。

It's like, okay.

我们叫它对立违抗障碍，孩子有这个诊断。

I have a kid with ODD, we call it.

但这对我有什么帮助呢？

It's like, how does that help me?

我能拿它做什么？

What do I do with that?

所以如果我看到一个孩子有对立行为，我会想，好吧。

So if I see a child with oppositional behaviors, I'm like, okay.

这种行为背后的功能是什么？

What's the function behind that behavior?

这样我就能想出孩子为什么对立的原因。

And so I can come up with reasons for why a child is oppositional.

我们都认为孩子发脾气、打架、大喊大叫、争吵。

So we all think kids who have meltdowns, who fight, who yell, who argue.

这背后的功能是什么？

It's like, what's the function behind that?

所以可能那个孩子其实很焦虑。

And so it may be that child is actually anxious.

我告诉你，很多孩子的对立行为是由焦虑和尴尬的情绪驱动的。

I'll tell you a lot of oppositional behavior in kids is driven by feelings of anxiety and embarrassment.

可能孩子是冲动的。

It may be the child is impulsive.

那个孩子撒谎、争辩、很快说“不”，是因为他们冲动，而且有多动症没治疗。

That child lies and argues and yells no quickly because they're impulsive and they have untreated ADHD.

也可能是那个孩子在理解社交环境和社交技巧方面有困难。

It could be that child struggles with understanding social context and social skills.

他们其实在社交互动上有问题，但表现出来却像是对立行为。

They actually have trouble with their social reciprocity, but they're presenting with what looks like oppositional behavior.

那个孩子可能感觉过载，处理感官信息有困难，所以变得不知所措、失控，表现出对立行为。

That child may be sensory overloaded and have challenges processing sensory information and therefore becomes overwhelmed and dysregulated and oppositional.

这样的例子还有很多。

The list goes on.

关键是，当我看到一个有对立行为的孩子，家人说“哦，有人告诉我们这是对立违抗障碍”时，

The point is is like when I see a child with oppositional behavior and a family says, oh, well, someone told us it was ODD.

我会想，那接下来怎么办？

I'm like, now what?

我想马上回到那个话题。

I wanna come actually right back to that.

我不知道有多少孩子能得到这种深入的了解和关注，但我担心的是，可能不够多。

I don't know what fraction of kids are getting that type of insight and attention, but my concern would be not enough.

我担心的是，我们正处在一个标签和代码不断扩大的世界里，而“那又怎样”这个关键问题却被忽略了，当然，在医学领域，没有哪个领域比这里更需要这个“那又怎样”。

My concern would be that we're just in a world of ever expanding labels and codes and the so what is missing when of course there isn't really a field of medicine in which the so what matters more.

比如，如果一个人有高血压、高血脂、胰岛素抵抗，理解背后的原因很重要。

If you think about this person has hypertension, hyperlipidemia, insulin resistance, it's important to understand why.

对。

Yeah.

但至少，即使我们不知道原因，我们也有很好的治疗方法。

But at a minimum we have great treatments if we don't know the why.

如果最终只是被判定为原发性高血压，我们根本不知道原因。

If at the end of the day it's just deemed essential hypertension, we have no clue why.

最坏的情况，我们可以给你开药。

Worst case scenario, we can put you on medication.

你知道，如果减肥不足以降低血压和改善胰岛素抵抗，至少我们有非常有效的药物。

You know, if weight loss isn't enough to reduce your blood pressure and fix your insulin resistance, at least we've got medications that work really well.

但是你知道，很多人会不愿意给孩子用药。

But you know, a lot of people would be hesitant to give their kids medication here.

我想详细谈谈这个问题，这更说明了为什么——如果你不明白这个孩子为什么会有对立违抗障碍，如果是因为感觉超负荷，那治疗路径和焦虑完全不同。

I want to talk of course about this in length, which is all the more reason why, boy, if you don't understand why this kid has oppositional defiant disorder, if it's because if it's like sensory overload, it's a totally different treatment path than if it's anxiety.

我同意。

I agree.

所以这是我这个领域面临的挑战之一。

And so this is one of the challenging things about my field.

而且，我还是要回到我的那些分类。

And, again, I'm gonna come back to my boxes.

我接待一个家庭时，实际上会非常坦诚地告诉他们，我们并不是什么都知道。

I see a family, and I'm actually pretty transparent with the families I work with regarding that we don't know everything.

我对他们非常诚实和透明，因为他们会问：医生，诊断是什么？

I am really honest with them and transparent because they're like, doctor, what is the diagnosis?

关键是，家庭都想要一个诊断，因为那有帮助。

And the thing is is families, they wanna find a diagnosis because it helps.

不知道发生了什么，确实很吓人。

It's scary when you don't know what's happening.

但我会耐心跟他们解释，确实有这些标签和诊断。

But I really walk them through that there are these labels and diagnoses.

但风险在于，他们可能会去找我这一行的人做测试，然后得到一个诊断。

But the risk is that they can see someone in my field and they do testing and you give a diagnosis.

比如说，我遇到过一些孩子。

Like, I have kids.

他们来的时候带着一份报告。

They come with a report.

上面写着这个孩子有对立违抗性障碍。

This child has ODD.

然后我就想，好吧。

And like, okay.

但这到底意味着什么呢？

Well, what does that mean?