When people think of supportive services for autism, they often imagine specially trained teachers, psychologists, social workers, or speech and occupational therapists. They don’t always think of psychiatrists. But they should.
Autistic children and adults often experience co-occurring psychiatric conditions. Some studies suggest that up to 70 percent of autistic people have attention-deficit/hyperactivity disorder (ADHD). Up to 50 percent suffer from anxiety disorders, and many autistic individuals also experience depression and other psychiatric conditions.
These conditions can have a significant effect on quality of life. Left untreated, they can wreak havoc on an autistic person’s mental and emotional well-being, sometimes having an even greater impact than the autism.
That’s why psychiatrists at the Duke Center for Autism and Brain Development are playing such a crucial role in the treatment and care of autistic patients.
J. Nathan Copeland, MD, MPH, assistant professor of psychiatry and behavioral sciences, and Gary R. Maslow, MD, MPH, professor of psychiatry and behavioral sciences, are both involved in autism care across Duke and beyond, from the clinic to the classroom to statewide consultation.
At Duke Health, they help pediatric patients and families navigate the complexities of an autism diagnosis. They identify co-occurring psychiatric conditions among these patients and help develop comprehensive care plans. They lend their expertise both to primary care pediatrics and to the division of child and mental health and community psychiatry, which includes child and adolescent psychiatry services.
Copeland and Maslow also devote substantial time to identifying other medical concerns that might be affecting an autistic individual’s health and overall outlook.
“If I see a ten-year-old boy who’s dealing with some aggression,” says Maslow, “I’ll sit down with him and first ask: Okay, why is this happening? And there’s often a medical answer.” The child might be hungry or constipated, for example, or have some other physical ailment troubling him. “Because of our training, that’s an area we understand and can help families and other caregivers think through,” Maslow says.
The discussion of that ten-year-old child’s clinical concern doesn’t end at the conclusion of the office visit. This past year, Maslow and Copeland revamped the Center for Autism’s child and adolescent psychiatry training clinic, which now includes four fellows and four attending physicians consulting together on every patient. That’s a robust supervisory ratio, with deep opportunities for case consultation and interdisciplinary learning, says Copeland.
“Every child psychiatry fellow who trains at Duke leaves here prepared to work with neurodivergent children and adolescents,” he says. “And some become so passionate about these children that they make the decision to specialize in this area.”
Statewide, the need for child psychiatrists far exceeds supply, and knowing how to care for children on the spectrum is becoming increasingly important for all providers.
When child psychiatrists aren’t available, primary care providers often fill the gap, but they still need expert guidance. Copeland and Maslow helped launch the North Carolina-Psychiatry Access Line (NC-PAL) in 2017, which began as a consultative service to primary care providers in six counties and has since grown into a statewide educational program. The team provides telephone consultation and other tools to primary care providers navigating the behavioral health needs of their pediatric patients, including autistic children.
A related enterprise, North Carolina’s Systemic, Therapeutic, Assessment, Resources, and Treatment program, or NC START, also benefits from the pair’s support. NC START is a statewide community crisis response initiative for individuals with intellectual or developmental disabilities and co-occurring behavioral and/or mental health needs. For the past three years, an interdisciplinary team of clinicians, including Copeland, has been reviewing the most complicated cases that come through the initiative, making recommendations to the patient’s care coordination teams and families for next steps in treatment. Copeland is seeing hopeful results: patients who receive this specialized consultation wind up using crisis services about 70 percent less than they would otherwise, he says.
You’d think those activities would be enough to fill a psychiatrist’s already-busy schedule, but Copeland and Maslow also operate at the policy level, lending their perspectives to legislative actions and initiatives that affect neurodivergent individuals. They’re helping Duke Health provide care for patients who receive the state’s new Behavioral Health I/DD Tailored Plans that launched last year, specialized plans that offer integrated physical and behavioral health services for members with significant behavioral health needs, intellectual/ developmental disabilities (I/DD), and traumatic brain injuries (TBI).
“We work closely with the state,” says Maslow. “We’ve had the opportunity to help [state leaders] think about the diagnostic journey of a family affected by autism. There are still structural barriers at the system level, based on where you live and who you are. We’ve been able to speak up about those.”
The work is complex and multilayered, but Copeland and Maslow understand these activities as interconnected. From the clinic to the classroom, from the consultative call to the statewide health initiative, they’re building connections and relationships, helping educate, diagnose, provide medical clarity, and inform the autism conversation.
“We’re trying to shine a light, through research and practice, on the systematic challenges that exist for these families—and then to suggest solutions,” Maslow says. “If we can do that, then at the end of the day, we’ve accomplished something.”