Our guest today is pretty incredible. Dr. Celine Saulnier is talking with me all about research and practice in the assessment of autism spectrum disorders, neurodevelopmental concerns, and adaptive functioning.
Gosh, this is going to be a long bio. She has done a lot in the 20 years that she’s been in our field. She started with her PhD at the University of Connecticut under the mentorship of Dr. Deb Fein. She then went on to postdoc at the Yale Child Study Center and she became the training director and then clinical director of the Yale autism program.
After several years, she was recruited down to the Marcus Autism Center and Emory School of Medicine in 2011, and she worked there to do many things. She was an Associate Professor within [00:01:00] the Department of Pediatrics. She was an investigator on many grants studying autism spectrum disorder. In 2012, she made a huge contribution and worked on the team to help get one of the national institutes of health autism centers of excellence grants.
She’s published in many leading journals for autism. She’s a member of the scientific advisory board for Autism Science Foundation. She’s also co-author of the Vineland Adaptive Behavior Scales, Third Edition and she’s co-authored two books on autism spectrum assessment and adaptive behavior assessment.
Now, Celine has moved on to the next chapter and she founded Neurodevelopmental Assessment and Consulting Services in Atlanta where she practices and completes assessments for neurodevelopmental disorders. She also consults with groups and [00:02:00] agencies across the country on a variety of topics.
So I’m very lucky to have her here today. It was a great conversation. This was a great interview and I’m happy to present it to you.
So without further ado, Dr. Celine Saulnier.
Hello and welcome to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. We have a fantastic guest with us today, Dr. Celine Saulnier. She is a licensed psychologist in private practice. She also does a lot of consulting around autism spectrum assessment.
We’re going to talk about many things, but I think we’ll probably center around ASD assessment and all of your work in that area. You have [00:03:00] a storied career, I think, from what I can tell with all of that. So I’m excited to have you on the podcast. Welcome.
Dr. Saulnier: Thank you so much. It’s such a pleasure to be here. The Testing Psychologist is my new favorite obsession, so I’m really excited to be part of the podcast.
Dr. Sharp: Oh, that’s great. It’s good to hear that from people. I started the group, it’s probably a year and a half ago now, and it’s just grown and grown. There’s so many people but I never know if it’s helpful or not helpful.
Dr. Saulnier: Well, my friend, Harry told me to go on because he said at least four or five times a day, someone is asking about ASD and it would be great to have you on here, but I’ll tell you, I’ve learned so much being in private practice, which is a new world for me, is a learning curve. So I just throwing out a shout-out to everyone in The Testing Psychologist. Thank you because they’re awesome. Love it.
Dr. Sharp: Nice. Oh, that’s so good to hear. [00:04:00] That is a cool thing about it. It seems like there’s a lot of give and take and there’s as much learning as teaching going on. So it’s really cool to hear that you’re getting some of them.
Dr. Saulnier: Yeah.
Dr. Sharp: And we’re lucky to have you. We were talking before we started to record and I said, when you joined the group, I was like, oh, this is a new person. You posted your website and I always go and check out people’s websites and just see what they’re up to.
And the more I read, I was like, ooh, we need to talk. You’ve done some great stuff in this field and have been connected to some really cool folks and sounds like you have a lot to share. So I’m thankful that you are willing to take some time and talk with me.
Dr. Saulnier: Thank you. I did recently just take a 180 in my career. And I, from graduate school, have been in academia of my entire career. So I spent nine years at the Yale Child Study Center [00:05:00] and then my mentor, Ami Klin, was recruited from Yale. After 21 years at Yale, he decided to leave and come to the Marcus Autism Center, which is a huge clinical care center in Atlanta and affiliated with Emory University School of Medicine.
So I relocated with him and spent seven years helping to pretty much transform the Marcus Autism Center into a center of science. So build up an academic research program there and did that. And then quality of life, midlife, time to reintroduce myself to my children, my husband, thinking, you know what, I’m going to go off on my own.
I opened up my own company, Neurodevelopmental Assessment and Consulting Services here in Atlanta. It’s been a wild ride so far, but what a change in my quality of life. I can’t even explain it. It’s wonderful.
Dr. Sharp: That’s why we do it. I feel like that’s the motivation for so many people. So that’s a huge shift, right?
Dr. Saulnier: It is.[00:06:00] Dr. Sharp: Well, it’s been, I’m just going to immediately go off script and ask what has been the hardest thing about jumping into private practice so far.
Dr. Saulnier: Without a doubt, leaving an academically rich environment where I always have an expert and a friend and colleague over my shoulder to say, hey, come look at this kid or what do you think about this, and just having all sorts of multidisciplinary minds surrounding me to help conceptualize something, even just for fun, even if it wasn’t about a case or a research project, just being immersed in that environment.
So, fortunately, I kept connected through grants and through consulting and through some organizations I’m affiliated with to academia and to my colleagues. So I still have access to that but definitely, on a day-to-day basis, it’s something that is a huge shift.
Dr. Sharp: Sure. Yeah, I think that that’s one of those things that people talk about a lot, like the isolation of private practice and especially coming from a place like that [00:07:00] where it sounds like y’all had a lot of give and take and just a nice community going on.
So let’s back way up. You’ve given some hints here and there, but I would love to hear about what your career has looked like, like where has your research focused and why autism and then, again, this transition to private practice.
Dr. Saulnier: Sure. So my career started prior to graduate school. I spent four years working with children with autism within treatment programs at various places. I fell in love with the disorder, with the people, with their families and just wanted to offer them something more than what existed. So that was my motivation to go into academia. I wanted to do research.
So I found Debbie Fein, begged her to get into her graduate program. So my interest in autism was the focus [00:08:00] of my clinical psychology degree. I knew through my entire training, I’m never going to be a therapist, I’m never going to be a quintessential psychologist. I was always in this for autism.
And so I fell in love with assessment. When you work with a neuropsychologist like Debbie Fein, you just fall in love with diagnostic testing, and then the natural transition from there to the Yale Child Study Center, working with Ami Klin, Fred Volkmar, and Sarah Sparrow.
I just honed my skills in early detection but lifespan comprehensive developmental assessments. It was at Yale that I met Sarah Sparrow and naturally got involved in the research on adaptive behavior profiles for individuals with autism and the extreme deficits that they have.
In 2010, when she passed away, completely unbeknownst to me, she literally bequeathed me the Vineland Adaptive Behavior Scales. [00:09:00] And so it was a huge honor to take on that legacy. And then I just started working with Pearson Clinical and over the next six years developed the third edition of the Vineland.
Dr. Sharp: Oh my gosh. Wow. So you found yourself all of a sudden thrust into a test developer role. It’s fun. I’m curious, I interviewed Steve Feifer a week or two ago, and we got into like, how do you even make that transition? And he was saying it was a wild ride. I’m curious what that was like for you to jump into that role.
Dr. Saulnier: Well, what was crazy about it is, suddenly you’re in a business environment, six years, I’m immersed in a business environment coming from academia. So every time I say something like, but the research shows, Pearson sitting here going, we don’t care. We’re a business. We’re selling a product.
And so you just have your mindset is like, wait a minute. And you just have to take yourself out of that academic [00:10:00] role and stick yourself into this business role. And that has been a struggle for me.
There are a lot of things about the Vineland that are absolutely wonderful and beautiful and a lot of things that if I had my say, would be refined a bit more, certainly the computer administration and the platform of it but overall though, it’s been a fantastic experience and a learning curve that I never would have expected.
Dr. Sharp: Mm-hmm. Oh my gosh, yeah. I could see that being really tough. I wonder, so are you allowed or can you talk about like any of those, were there any major sticking points where you were like, but the research says, and that just couldn’t work with the test development?
Dr. Saulnier: That they pretty much right off the bat, nipped in the bud. I think probably one of the sticking points for me was the computer platform. In 2010, knowing that the things that [00:11:00] Q-global couldn’t do then, and foreseeing in the future, we’re looking at 10, 15, maybe even 20 years that the Vineland is now on this platform. If it already has these limitations in 2010, what are we looking for in the future? There was just no wiggle room there.
I even brought in a consultant that I knew from another computer programming company that was saying we could do this kind of thing. It just didn’t come to fruition, but I’m hoping and I’m hopeful that Pearson has been wonderful to work with, that as the Vineland evolves as Pearson evolves, that maybe those platforms can improve a little bit.
Dr. Sharp: Yeah, that’s the hope. I think that’s probably true across the board. Everyone’s going to online or digital administration in some form or another and I have to think that’s where all the money and time and attention are being devoted because it’s…
Dr. Saulnier: Well, can I tell you this? And [00:12:00] I would love your perspective knowing so many psychologists. From a Pearson sales perspective, no one’s buying on online platform. Everyone is sticking to the old paper form.
And is it because we as psychologists are so antiquated that we have a hard time, like those of us meeting old, like mid later career don’t want to shift to something that novel whereas maybe if we only knew computer programming from graduate school on, we’d be more apt to use like the WISC-V Integrated, those types of platforms.
Dr. Sharp: Yeah, for sure. I think that’s a big part of it. I do. I think that the, how would I phrase it? The familiarity is a big factor because even for me, I’ve talked a lot on here about, I was a very early adopter of Q-interactive. I love technology. I like new things and shiny things but I was definitely trained in [00:13:00] paper administration and it’s been hard to totally shift over even though I want to, and I think there’s something to be said for just being locked into your way.
Dr. Saulnier: Well, I’ll tell you, I have the WISC-V and several other assessments on Q-interactive for my new practice, but I haven’t had to use them yet. And every time the phone rings, I’m like, oh God, I hope I don’t have to give the WISC-V because I am that creature of habit that, where’s my paper form.
Dr. Sharp: Sure. Well, I think too, there’s still some, I don’t know if suspicion is the right word, but skepticism may be around the transfer to the digital platform. I think that’s less so with maybe something like the Vineland, but certainly the more cognitive tests, it’s hard to know for sure if it’s going to be equivalent or measuring the same thing. So there might be some hesitation there too. That’s interesting to hear that perspective though.
So [00:14:00] let me jump back a little bit to your research. Can you talk specifically about what kind of research you’re doing in the field of autism?
Dr. Saulnier: Sure. So in adaptive behavior, my research has focused on the gap between cognition and adaptive functioning in autism, particularly in individuals who don’t have cognitive impairment. So that gap is associated with poor outcome into adulthood because we just naturally assume if a person has intact cognition and intact language, they are translating all those skills to everyday life and they’re not whereas if someone has significant intellectual disability, we’re really good as clinicians to make recommendations to say, hey, teach that person to dress themselves, to clean themselves, to feed themselves, to take the bus but we don’t do that for intact cognition individuals.
So that research has been a strong focus. And then working with Ami Klin and my colleagues at Yale and then at Marcus, we really ended up focusing on early detection [00:15:00] of autism symptomatology in infancy, which was fantastic. It was really eye opening to see the earliest emerging signs of developmental derailment.
And so using not only clinical measures and behavioral measures but biomarkers like eye tracking and neuroimaging and genetics and looking at, can we actually detect the onset of autism before the full blown symptom arises by age two? So that research became a big focus of mine.
And then I’d say a third area of research that I got involved with through a network study with colleagues at UCLA and St. Louis was in African American, so cultural differences and cultural diversity in autism. So there’s so many disparities in access to care and delays and diagnosis and then obviously cognitive [00:16:00] presentation. So that area research was something that I was super passionate about.
So now that I’m in private practice, I kept my adjunct associate professorship at Emory. So I still have contact with these colleagues and hopefully will continue to publish and keep one foot in academia in that regard but it’s just I’m a little bit farther removed from it now.
Dr. Sharp: Right. I feel like there’s so much that we could unpack from all of those areas. So I’m like sorting through in my mind, like what is most… could we focus on the markers in infancy for autism? I think I’m super curious about that.
At least in our clinic and I probably should know how this compares around the country but we’ll go down to two-ish, two and a half is when we start to really do assessment with kids for autism. So I’m curious, what were y’all finding from infancy? Is there anything that we could look for as [00:17:00] clinicians or things that…?
Dr. Saulnier: Yeah, in us as clinicians and the thing is, all of us as clinicians, the burdens on our shoulders to make that call. And nobody wants to make a call on a beautiful 12, 15-month-old to say, we’re giving you a lifelong behavioral disorder here. Not to mention that DSM criteria are atypical behaviors that were created for adults and then downward extended to children certainly not infants and toddlers.
So research shows that a lot of the early risk factors are not the presence of these atypical behaviors but the absence of typically developing milestones. So what would cause us concern is limited and different vocalizations; the limited eye gaze, the lack of joint attention.
You’re not going to see hand flapping because 12-month-olds who are typically developing will flap their hands when they’re excited so that’s not going to be a risk flag but [00:18:00] posturing or clutching onto objects would be, and that would emerge into the more stereotypical behaviors that we think of for autism.
And lack of responsivity to name, lack of social contingency. So you smile at a baby, they smile back at you and then it becomes a dance in the same way that we vocalize with infants, that is a reciprocal dance. So ba, ba ba, and then the baby goes, ba, ba, and you go, ba, ba, and it just goes back and forth. That reciprocity is absent or impaired.
So it’s collectively looking at these things, how many of these risk factors are you seeing. By the time they all converge and you have full blown autism at two, when they’re coming into your clinic and most clinics, what we’re finding with research is it’s still optimizing outcome because we’re treating young enough to get rid of language delays in an affiliated behavioral disruption [00:19:00] and self-injury but it’s still a lifelong disorder.
Maybe less than 10% of people even diagnosed at age two will have an optimal outcome. And that’s Debbie Bond’s research. However, we’re wondering if you catch it in infancy as the derailment’s starting, before the full blown disorder is there, maybe you can course correct.
Dr. Sharp: Were you able to think about… could you identify any interventions that early that are more helpful than others?
Dr. Saulnier: People are starting to develop them and they’re still in the experimental phase. They’re very parent oriented, of course, parent coaching because you want that natural interaction between the parent and the baby. I think that it’s just too soon to tell how effective those will be.
Downward extending things like ABA or even some of the NBDIs, the Natural Behavioral Developmental Interventions, Early Start Denver model and JASPER and [00:20:00] things like that that were created for toddlers, even downward extending those to infancy, it’s still premature to say whether or not they’re effective.
And then everyone’s focusing on biomarkers to see if there is some type of fix in the brain. But I think a lot of people in our field, and this could be a podcast in and of itself, is the nature of… we don’t talk about cure as much anymore for something like autism because of the whole neurodiversity movement.
And we are just talking about optimizing outcome and fostering the strengths that every person has and not saying to take away the autism because that in a way is taking away the essence of who the person is. It all depends on who you talk to and how they feel about that.
Dr. Sharp: Oh, of course. We or I talked to Joel Schwartz about neurodiversity two podcasts ago, which was really illuminating. It was good for [00:21:00] me. It’s just that exercise of bending your brain a little bit to think about things totally differently.
Can we talk about biomarkers, where are we at with biomarkers for autism? Is that legit or?
Dr. Saulnier: Well, so my colleagues were focusing a lot on eye tracking. And so, for example, when you have babies watch movies or interactions with caregivers playing, singing to the baby, talking to the baby, even as early as the first six months of life, this is Ami Klin and Warren Jones’s research, babies who will go on to develop autism later in life don’t look at the eye region of the face. They focus on mouth, body, and object.
And so that biomarker detecting that early is more predictive of their future autism than even the ADOS is with itself over time. So that becomes a question, will that biomarker be a [00:22:00] diagnostic tool? So can eye tracking be something in a pediatrician’s office that can predict autism later so that maybe you can do something to course correct?
So my colleagues’ research is actually unfolding into an FDA trial that’s ongoing right now. And if that FDA trial is successful, then you could see this eye tracker be used commercially in a pediatrician’s office for examinations.
Dr. Sharp: Okay. So it is on the way to a product, I suppose.
Dr. Saulnier: Exactly. And then there are so many others that people are doing at other labs and even at Marcus, neuroimaging genetic biomarkers and EEG biomarkers. So it all depends on what type of research, what they’re predicting as what you do once you identify it.
Dr. Sharp: Mm-hmm. Absolutely. I’d like to ask about each of those too but the thing that popped up for me that I imagine others maybe are thinking about is, do you foresee us being out [00:23:00] of a job at any point as behavioral assessors?
Dr. Saulnier: We only hope, if it got to that point that it would improve the lives of people with autism so much they didn’t need us, then absolutely I would bow out and say, I’ll go do something else. However, even if you diagnose autism with a biomarker, you know nothing about how to treat that child. You don’t know that child’s cognitive profile, their language profile, their strengths and weaknesses, their adaptive profile, all of that still requires us.
Dr. Sharp: That’s relieving and well said. Nice. So what about those other biomarkers? Where are we at with genetics and you mentioned EEG. I know that’s out there. Is anything else showing promise in terms of being truly discriminatory for us?
Dr. Saulnier: Sure. I’m talking completely outside my wheelhouse. This is not my area of expertise, [00:24:00] but let’s take genetics. Over 100 up to maybe 900 genes have been identified as being associated with autism.
Each one of those in and of themselves maybe associates with a very tiny percent of autism. So maybe 0.5%, but you put all those together and they account for maybe 20 to 30% of the autisms. So there’s a 30% chance that if you do genetic testing on a person with autism, you’re going to identify a genetic association.
Some of those genetic disorders, you can pinpoint what genes are impacted by the deletion or mutation that they have. Phelan-McDermid syndrome, for example, is a mutation on the SHANK3 gene. There are some experimental treatments, certainly with rodents. [00:25:00] They’re doing the mice models first and then do rats.
If you can course correct the genetics using these treatments. So in a way that the genetic biomarkers would probably be thinking about ways in which you could intervene to change the genetics of an individual.
Sarah Schultz and Longchuan Li at Marcus memory are doing infant neuroimaging. So if they do multiple scans over the first six months of life and they identify the derailment in neurodevelopment and then at the same time you intervene with these parent-focused interventions to keep that infant engaged when they naturally want to disengage, maybe you can change the neural firing of what’s going on in the brain to course correct the brain. It’s too early to tell but we’ll see.
Dr. Sharp: It’s exciting stuff. That’s super exciting. I know that we… there was a discussion in the Facebook [00:26:00] group the other day about the role of genetics in autism. It’s a little different, we’re taking a little different tack and I imagine that a lot of people maybe didn’t see that discussion so I’d like to get into that a little bit, because this is something that has been controversial for me in the past. There was some discussion, differing opinions in the group too.
So what I’m alluding to, for those who didn’t see it, is what is the role of a genetic syndrome or disorder in the diagnosis of autism and do we diagnose autism independently of a genetic concern or does the genetic concern service the umbrella that encompasses all autism symptoms and that is the standalone diagnosis? So I’d be, yeah, if you’re willing to dive into that again, I’m curious.
Dr. Saulnier: Well, I started it, so I guess I have to clean it up. I posted about a case I’m going to see of a [00:27:00] girl with Phelan McDermott syndrome who also has autism and it sparked a debate. Well, when the genetic syndrome of Phelan McDermott override the autism diagnosis. I said, not necessarily because these are the identified genetic disorders that are associated with autism.
So we are basically uncovering the genetic cause that’s controversial but some people would say the genetic cause for that girl’s autism. From eligibility perspective, this girl’s not getting appropriate intervention in her schools because nobody knows what Phelan McDermott Syndrome is or what the symptoms are and so if she’s tagged as other health impaired, she’s going to get whatever type of treatment for the genetic syndrome that no one understands but if she’s listed as autism spectrum disorder with this genetic condition as a specifier [00:28:00] then she’s going to get more targeted social communication interaction treatments that she wouldn’t otherwise get under the other health impaired.
So there’s a debate either way. I now will play devil’s advocate and say that I’ve worked with enough of these genetic disorders to know that when you assess for the autism symptomatology, many times it’s a different autism. I’m still checking the boxes. I’m still giving the diagnosis of ASD but it’s a qualitatively different autism than idiopathic autism, meaning like an autism that doesn’t have a known cause. And so that then can be the argument, why would you then call it autism?
Dr. Sharp: Of course. I’m glad that you bring that up because I was going to ask that question either from your research or colleagues just being steeped in that area; is it fair to say there is a classic autism that [00:29:00] has a certain maybe genotype, if that’s the right word versus this other, like you said, alternate, I don’t know, I forget the word to use, different kind of presentation of autism that still checks the boxes. The symptoms are there but it’s qualitatively different. Can you make that distinction?
Dr. Saulnier: I think because of whatever decisions were made to make it this spectrum. That you have people who are nonverbal all the way to exceptionally verbal, from extreme cognitive impairment to superior cognition and then autism symptomatology that could be mild to super severe, then behavioral symptoms that run the gamut.
How can you say all of that is the same disorder? Well, the common thread is this social disability, the social communication interaction deficits with the restricted and repetitive behaviors. They all have those.[00:30:00] So maybe it truly is that we’re seeing autisms and they’re all qualitatively different because they all have a different underlying etiology or as we discover them, should we be just naming them something else? And that I think the field of genetics is moving so fast that we almost can’t keep up with it in that regard. So I think that’s still to be determined on where the field will go in that way.
I know there’s a huge controversy right now in the field of how can you call the nonverbal person versus the self- advocate who’s on TV and saying, nothing about us without us and how can you say these are both autism and have the self-advocate advocate for the non-verbal or minimally verbal.
I know that families and even researchers will say, just please call these two things something [00:31:00] different, just so we can move on and actually target and research these specific areas of commonality in those groups, but I honestly don’t know where the field is going to go regard.
Dr. Sharp: Yeah. So do you know if we’re at a place with the genetic research, I know you said this is a little outside your scope but are we at a place with that where we can say like, yes, there’s a well-known enough genotype that equals typical autism versus some of these genetic disorders having a different, now I’m losing the right words but it’s…
Dr. Saulnier: No, it’s hard to say because when we identify a lot of these genetic disorders, by the time your genes take a hit; you’re impaired. A lot of these genetic disorders have intellectual disability, they [00:32:00] have medical comorbidities, seizures, cardiac defects, they can have a host of other things.
So in a way, that is qualitatively different in and of itself than classic autism that really we’re just seeing the core social disability and that’s it, not murky by anything else. So maybe in that regard, these genetic disorders should be classified by their condition and not by the autism but then how do we account for their overarching social disability on top of it?
Dr. Sharp: Yeah, it’s a complicated question. I appreciate you being willing to dive into it a little bit. It is complicated. I’m really curious to see where we go.
I have a mentor down at our local children’s hospital, who I consult with frequently. Her view is similar to yours, if I’m understanding right, that [00:33:00] we would diagnose the autism on top of the genetic disorder to provide that extra layer of specificity or intervention. Exactly. Complicated question, though. It’ll be interesting to see where things go.
Before we totally leave that topic, could we talk about… I guess I have two questions: One, some of those common genetic disorders that may look like autism or produce autism-ish symptoms. And then the other question is kind of the reverse; if we’re seeing a kid, how would we know to refer for genetic testing?
Dr. Saulnier: Sure, the easier answer is if you see the dysmorphology and a certain genetic syndrome comes to mind, then you’re specifically referring, I want this child tested for Williams syndrome or Angelman syndrome or Down syndrome or whatever, based on the dysmorphology that you would expect Fragile X.[00:34:00] On the flip side, I think there’s enough genetic evidence now that a paper was published. I think the first one came out in 2009 and the second in 2013 by the American genetics. I should know it, and I don’t. It’s like the medical genetics journal and it’s huge and basically said it’s now a recommendation that every individual who’s diagnosed with autism should receive genetic testing.
And so when I make a diagnosis, it’s one of the first recommendations in a report. Go to your pediatrician and ask for an autism screen. So it’s usually a chromosomal microarray and ruling out Fragile X because that’s one of the most common associated genetic disorders unless there’s a dysmorphology that would make someone think just to do a specific gene search.
I was just saying this to a family [00:35:00] yesterday, with a 20-year-old. He had genetic testing three times in the past but when he was a young child, he’s now 20. We know so much more now than we did even last year. So I recommended genetic testing again.
The question that comes most often with a family is why? What difference is it going to make and would we do anything differently based on the findings? A lot of these genetic conditions because of the medical comorbidities is reason enough for me to recommend saying, yes, if your child might have a heart defect, might have X, Y, or Z, that I think is worth investigating.
Not to mention that some of these, not a lot, but some are inherited mutations, so that has an impact on the whole family, even the unaffected siblings of the child with disability in their own family planning. So in that regard, it makes sense.
Dr. Sharp: Absolutely. Yeah, [00:36:00] that does make sense. That’s a little bit surprising, actually. I should know that but it sounds like it’s almost standard of care then.
Dr. Saulnier: I think its standard care.
Dr. Sharp: That’s great. Okay. That’s good information. Well, so that might be a nice segue into more clinical discussion. You’ve transitioned to private practice, so what does that look like for you? What are you doing in your practice?
Dr. Saulnier: Well, it’s fairly new. I just set up the shop in June. I should say I spent the summer having a very slow transition, given the 180 in my career that I did. I took a lot of time off, vacations, and set up my office. I have a beautiful space. I have multiple rooms here. This is my office.
Dr. Sharp: That’s your office, oh my gosh. I thought you were at your house.
Dr. Saulnier: No, it’s my office. I have a testing room. I have a room that’s unused. I have a kitchen. I have a waiting area. It’s big. [00:37:00] I set that all up and then the calls have been trickling in and I have focused so much on infants and toddlers for the past 10, 15 years. I’ve been pleasantly surprised that the majority of the clients I’ve had so far have been adults.
So to me, it’s so exciting to delve into these older individuals and their presentations and really working with families on the flip side of the spectrum than I have been focused for the past 10 years. So that’s been exciting.
And then I wasn’t expecting that the consulting opportunities were going to come in as much as they have, so that balance of trying to figure out, okay, I can only see so many patients because I have these consulting opportunities, several genetics grants that need oversight for [00:38:00] the psychological assessments that go on for the grants.
Then also, so many clinical trials are now using the Vineland as an outcome measure. So being asked to consult in that regard on the new Vineland-3. And I’ve always given workshops around the country on assessment and autism in general. So next week I’m in Alabama and Florida for two different workshops to give.
So I love having that balance because it keeps me in so many different worlds and not just like you were saying, like in that isolated confounds of my actual practice, because then I think I would probably start having a paradigm shift reaction like, oh no, what did I do?
Dr. Sharp: Yeah, I know, it’s nice to keep a foot in both worlds. So let me ask about, we do focus on businessy stuff a fair bit and practice development. I’m curious how you’ve [00:39:00] been building your practice; where are you marketing? How are you marketing? Where are you getting your referrals just starting out?
Dr. Saulnier: Yeah, so I’m still in the process of doing that. You’re reminding me that I had a brochure made that I haven’t even printed yet.
Dr. Sharp: I’m sure you’re not alone.
Dr. Saulnier: I should do that. So right outside my window here is a pediatrician practice and the owner of that practice is my landlord. So I started with her group of pediatricians and educating them on the importance of early detection and to take the burden and onus off of them of saying this might be autism and sending them to me.
The downside is that for now, because this is so new to me and I have been immersed in academia, I’m not taking insurance. A lot of their families who are in need, I can’t see right now or I’m not seeing right now because I don’t take any insurance.
Dr. Sharp: It’s hard.
Dr. Saulnier: So it’s word of mouth. The Marcus [00:40:00] Autism Center, my colleagues there, they have 700 to 900 people on their wait list for assessments. So…
Dr. Sharp: 7900?
Dr. Saulnier: 700 to 900, 700 or 900 people on the waitlist.
Dr. Sharp: That’s still a lot
Dr. Saulnier: Is remarkable. There’s no shortage of need in Atlanta. There’s an Emory Autism Center. There is the Marcus Autism Center and there are a host of people in private practice and there’s still a huge demand.
And then others are just word of mouth through my career. So the person that I saw yesterday is an international family and that was solely through connections of being in my career.
Right now, they’re just coming in at a slow pace, which I’m okay with. When I need them to start coming in more, I’m going to be on The Testing Psychologist asking for recruitment advice.
Dr. Sharp: We would welcome that. It’s a whole another level. I feel like there are levels to this, [00:41:00] right?
Dr. Saulnier: Yeah.
Dr. Sharp: You start and then you figure out how to grow. That’s great. I was going to ask about the battery. So let’s get real practical. You’ve done all this research; you’ve got that side. How does that translate to clinical practice?
Dr. Saulnier: So my ideal battery for autism would involve a developmental and or cognitive assessment and adaptive behavior assessment, a diagnostic interview and then the diagnostic assessment. So I would always do an ADOS. I wouldn’t necessarily do an ADI unless I feel the need to, but I would do a very comprehensive diagnostic interview. And then…
Dr. Sharp: I’m sorry, can I interrupt you real quick and just break that out a little bit. What would convince you that you need to do an ADI-R?
Dr. Saulnier: So, for example, I had an adult two [00:42:00] months ago where I wasn’t sure based on the ADOS that this person had autism. He was a head-scratcher and I felt, I can sit here for an hour and just think of questions to ask about diagnostic symptomatology with this mom or I can just give an ADI and have the ADI do it for me.
That was super helpful because he had a prototypical early development for autism that I can now use this measure to help corroborate my diagnosis and yet I wouldn’t recommend that for traditional clinical practice. It’s too cumbersome. It’s never reimbursed but for research purposes, it’s ingrained in my soul because in research, you have to do the ADI and the ADOS.
And so I’m very much about that comprehensive view. [00:43:00] What I’m missing that I am so used to having in academia is a speech pathologist standing right here next to me, especially in infants and toddlers. That differential is critical about the speech language and communication impairments.
I have them on speed dial in the event that I need them for my evaluations. Ideally, I got this space so that eventually I can have multidisciplinary staff in the clinic so that I can get back to that.
Dr. Sharp: Is there anything that we can do as psychologists to do a lay person’s speech assessment if you don’t have that luxury, anything we would look for with those younger kids?
Dr. Saulnier: That’s a great question. If you know they’re going to have impairments, then doing a battery like the PLS or the self, those are going to flesh out your wrote speech and language [00:44:00] areas of vulnerability.
It’s the higher-functioning kids that are going to ace those the same way they’d ace a WISC. They’re going to have average to above-average scores. They’re going to get average to above-average scores on the language measures too.
Good speech pathologists know the measures to get into the theory of mind and the linguistic skills that trip up our higher cognitive folks, like the Test of Narrative Language or the DELV and some of these other ones.
I guess, as psychologists, we can learn them and administer them. It’s just the expertise of the speech pathologist that I feel is critical. Also for the nonverbal and minimally verbal, the augmentative communication assessments, it’s just something I’m not going to be able to do.
Dr. Sharp: Sure. A whole another world. What do you like for that early developmental assessment measure? So those kids who or maybe can’t do the WPPSI or might [00:45:00] be just too young or too nonverbal?
Dr. Saulnier: This is going to cause a ruckus in The Testing Psychologist but I come from the research world where the Mullen Scales of Early Learning is the go-to test and it’s so antiquated. The Mullen are from the late 1980s. It has wonderful strengths and I can do it with my eyes closed. So it’s my go-to measure.
Bayley, obviously it would be the go to test, except the Bayley only goes to a much younger age. I don’t even know if it’s four whereas the Mullen goes to 60 months. And so for your preschool-age kids that are impaired, you can still get standard scores with the Mullen whereas you wouldn’t be able to get with the Bayley. You’d have to move to something else.
If they are a little more advanced than the Differential Ability Scales; that’s my go-to cognitive because it has the teaching items and the Wechsler [00:46:00] scales do not. The Wechsler scales and even the Stanford-Binet are so verbally loaded that it’s very hard for people with autism, even with intact speech, to comprehend that level of instruction without you being able to demonstrate what you’re asking of them.
So you might misinterpret a cognitive impairment when it’s really, they don’t understand what you’re asking of them. They have this skill, the ability, they just need to be able to show you.
Dr. Sharp: Right. Sure. Yeah, that’s an ongoing question in the group but also, it’s just relevant right now in our practice, I keep talking with our folks about what do we get for those younger kids where we need to. It’s hard to find the one, and of course, we’re trying to balance costs with effectiveness and it’s hard to find the one measure that works best.
So in addition to the clinical practice, you do, like you said, some consulting. It sounds like on [00:47:00] a bigger level, though. You’re consulting with groups and not so much individuals necessarily on their own practices.
Dr. Saulnier: Oh, right. No, with academic groups or professionals like educational institutions, I do a lot of my workshops for the field of school psychology. So I’m going in and training the school psychologists who are assessing the kids within the school systems, which is a whole world in and of itself; school psychology versus clinical psychology can be a different world and I love school psychologists, and I love going to NASP. It’s so much more fun than APA. I just love it.
Dr. Sharp: And it’s going to be in Atlanta next, right?
Dr. Saulnier: I know. I’m doing a workshop.
Dr. Sharp: That’s right next door. Nice. I’m thinking about going to that one.
Dr. Saulnier: Oh, let me know so we can meet. [00:48:00] I would love to get into individual consulting and working with families and especially on an international level.
I have some wonderful colleagues and friends who do that already and they go all over the world and they’re doing assessments but also informing treatment and then they do a lot of telemedicine once they get back here. I would love to move into that arena a little bit more at some point.
Dr. Sharp: Sure. I can hear people as they’re listening, thinking, oh, that sounds great. How could I do that? Do you have any idea how to do that? How would someone move from practice…?
Dr. Saulnier: What I found through speaking engagements, it’s all, you give one, someone hears you and likes it. They refer and you get another and get another. So I would imagine that the international consulting is the same way; you work with one [00:49:00] family, if you can get the inroads to one family and you do a good job, that family is going to talk and refer to another family.
Dr. Sharp: Right. I’m going to ask a dumb question, which is, do you have any idea where to find those international families? Are they here for school or…?
Dr. Saulnier: It’s through probably conferences and speaking engagements is the best way. If you have an opportunity to present at an international conference that has parents, family members or school providers there, and they see you present and say, you know what, this is worth us traveling to find out more about.
And then places like Marcus and certainly Yale, they were just international in and of themselves. People would come from all over the world to be evaluated at the Yale Child Study Center. So I just benefited in that regard by being in the institution and being [00:50:00] surrounded by the colleagues that I was, so got that exposure in that regard.
Dr. Sharp: Sure. As we talk, it seems like you’ve either, I don’t know if it was deliberate or not, but you’ve been in so many fortunate situations to really set up your career path. That’s really…
Dr. Saulnier: Absolutely. I wouldn’t change a thing.
Dr. Sharp: That’s awesome. That’s really cool. And the way that you speak of it, it’s clear that you care about what you’re doing and are just highly invested.
Dr. Saulnier: Oh, thank you.
Dr. Sharp: I know that people can’t see us. We’re doing a video interview as well and your face is just beaming. And this whole time you’ve been super animated. It’s really cool to see that.
Before I let you go, I would be remiss not to ask about the difference in boys and girls with autism.
Dr. Saulnier: That is another topic near and dear to my heart. [00:51:00] Clinically and anecdotally, every time you do an assessment on a girl, you’re thinking, wow, they’re so qualitatively different than boys. Every once in a while, you’ll get that prototypical classic girl but that’s rare.
And so even those you think this still is closer to the prototypical girl because they made it to the clinic to be evaluated, the majority of girls are out there not getting detected and falling through the cracks because they have enough of a social ability that people think that can’t be autism and yet they are struggling so significantly.
And what happens is because they go undetected and they have enough social ability to know that they’re struggling, their psychiatric comorbidities are striking. So the anxiety and depression and even suicidality is really severe. And that’s usually what brings the person [00:52:00] into an assessment rather than the autism symptomatology.
And certainly in the workplace, when there is a lack of structure and support that they have in the educational system, then they’re going to fall through the cracks there. So there finally are initiatives, both research-wise and clinically, I think, to better understand the female presentation.
I sit on the scientific advisory board for the Autism Science Foundation. That organization was founded by Alison Singer, who is a mom of an adult girl. She started the Autism Sisters Project, which is a research-based initiative to focus on the unaffected girls in families of people with autism that get missed or why are they unaffected. How are they spared? What’s the female protective effect that we have so many more boys than girls?
Finally, people are doing research on this, and I think [00:53:00] the answers are still yet to come, but we know there’s a qualitative difference and we know that there probably should be differing diagnostic criteria. Some may argue differently from me but we’re getting there.
And so I think that if there are anyone out there that has a girl and they’re perplexed and they’re scratching their head, don’t discount that it could be autism.
Dr. Sharp: Right. I know you mentioned anxiety, depression, suicidality, perhaps. Are there other things we might look for in girls to at least be curious about autism? Other things you might see that we’d want to pay attention to?
Dr. Saulnier: I’m trying to think, if there’s anything qualitatively different in stereotypical behaviors, they might not be as pronounced or prototypical. If a girl has a genetic defect, she takes a harder hit. And that [00:54:00] raises questions about the protective effect.
So on the flip side of the higher cognitive girls that fall through the cracks in school, you have the really impaired girls that probably are just carrying a diagnosis of intellectual disability in their genetic disorder and no one’s thinking autism’s the forefront either.
So I think just knowing that there are those two varying presentations of girls is good and just not relying so much on one diagnostic measure and using your clinical judgment and knowledge because a lot of the girls that I’ve diagnosed with autism wouldn’t meet criteria on DSM-5 and/or an ADOS, for example.
Dr. Sharp: Yeah. I’m so glad you said that. That question was sort of formulating, but it really crystallized when you said that. I’ve seen many girls who, like you said, would not strictly meet the criteria but they had [00:55:00] autism, so I’m curious how you might phrase that in a report to justify, I don’t know if that’s the right word, but explain, yes, this is a girl with autism but it looks different than… how do you work around them?
Dr. Saulnier: That’s when I might pull the ADI because their diagnostic history, their early developmental history is often telling that they’d have enough criteria and remember the DSM-5 is current or by history, so you can use the history to advocate in that regard.
Other measures, if they’re old enough to do self-report measures of things like the Social Responsiveness Scale because the SRS actually has norms for males and females, which is nice. The ADOS doesn’t, other measures don’t go by gender.
And really it’s clinical judgment. Making a strong case [00:56:00] for your whole comprehensive assessment and why you think, and then educating the reader on presentation in girls, and maybe including some references in there of some research that’s been done, that this is a messier presentation for lack of a better way to describe it and it’s not going to be prototypical.
Dr. Sharp: Yeah. It’s good to hear you say that. That’s the approach that we take here at our clinic. It’s like an extra paragraph that goes in the report that basically says autism in girls is different than autism in boys. Here’s what it might look like and here’s why it might not be caught. Okay. That’s so great. It seems like we’re on the same page, which makes me feel good.
Dr. Saulnier: Me too. It’s nice to hear that from you.
Dr. Sharp: Nice. I’m glad we can agree. We’ve covered so much and I just really appreciate all the time that you’ve given us. Before we wrap, are there particular resources or researchers or projects out there that if people want to learn more, you might point them in that direction? [00:57:00] Where can people go to learn more?
Dr. Saulnier: The Autism Science Foundation is a phenomenal resource for scientific research going on and also for anyone with questions about vaccines, there’s a whole page of resources in the literature out there to say vaccines don’t cause autism. So you just have to send a parent in that direction to say, look here, that’s it.
Autism Speaks and Autism Society of America for Families. And then, for exciting research going on, then there’s the International Society for Autism Research, INSAR. They have an annual conference every year, and this year will be in Montreal, in May.
And then certainly places like the Yale Child Study Center and the Marcus Autism Center and lots of other wonderful places throughout the U.S. and the world.
Dr. Sharp: Nice. And if anybody happens to want to check in [00:58:00] with you or ask you questions, are you open to being contacted?
Dr. Saulnier: Anytime. So my email is firstname.lastname@example.org.
Dr. Sharp: Got you. That sounds awesome. I’ll put all of that information in the show notes so that people can find that and continue to learn more about this topic, which is fascinating.
Dr. Saulnier: Thank you so much. It’s been such a pleasure being on.
Dr. Sharp: Oh my gosh. Yeah, no thank you for being willing to come and chat. This has been fantastic. I really appreciate it.
There you have it, everybody. What an interview, my gosh. I kept coming up with these questions and I was like, this one’s going to stump her but nothing ever did.
And y’all couldn’t see, I’ve been doing video on my podcast lately, which has been really a nice enhancement to the whole process and I think helps with [00:59:00] the conversation flowing naturally, but y’all couldn’t see but Celine, like I said, at one point, just had this amazing smile on her face and presented such a positive attitude throughout the interview.
She was really a pleasure to talk with and I highly recommend if you ever had the chance to cross paths with her to make that happen. She’s very knowledgeable and very personable.
I hope you took a lot from this interview, I sure did. Got some additional interviews coming up that I think are going to be pretty fantastic as well. In the meantime, if you are building or growing your testing practice, feel free to reach out for any support that I might be able to give you. There are a number of paperwork packets that might be helpful in your private practice journey. I put together an administrative packet, a clinical packet, and a psychometrist training manual that are all available at [01:00:00] thetestingpsychologist.com/paperwork. You can use the code podcast to get 20% off your entire order.
And if you’re more in the mind for one on one coaching, reach out to me as well. I have, I think at this point, maybe just one more spot available for one on one coaching. And then I’m going to close that down and really transition more to doing mastermind groups because that’s what I love to do and I think people really benefit from that format. So probably one more spot for individual coaching before that closes for a few months.
And if you’re interested, reach out, again, at thetestingpsychologist.com and we can talk for a few minutes complimentary and just see if that’s a good fit for you. And if not, talk about what might be a good fit.
All right, y’all. Take care and enjoy the fall, whatever that looks like for you. We did not get a whole lot of fall. We got 8 inches of snow a week ago and all our leaves are gone. And we’re just headed full [01:01:00] steam into winter, but hopefully, you’re having a little bit of fall. I know my family in the South is actually in an unnatural state of heat right now, so maybe some of y’all are too.
Either way, take care. Talk to you soon. Bye bye.