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 (COVID-19) crisis continues, we hear more and more about the current—and projected—mental health fallout from illness, lockdown, job loss, forced relocation, loneliness, loss of friends and family, and death. Data about the direct neuropsychiatric sequelae of COVID-19 infection in addition to the indirect social or economic consequences are also mounting. Yet we do not hear about individuals with social anxiety disorder, or individuals on the high end of autism spectrum disorder (ASD), who are also socially anxious and relieved to be working from home.

Free from the social pressures of the job site, many of these individuals report feeling less distress overall. They are not necessarily free from anxiety altogether; their anxiety focuses on fears of being forced to return to offices when the epidemic ends. They are perturbed by the prospect of sacrificing the social obligation-free sanctuary that they have serendipitously and unexpectedly enjoyed during this strange time.

 taken of a group of workers; it found 80% wanted to continue to work remotely at least part of the time after the pandemic. Individuals with social anxiety disorder presumably comprise some small part of the 80%, yet it is unlikely that all 80% of the WSJ sample want to work remotely for the same reasons as the patients I am discussing. The article, “Is a Home Office Actually More Productive? Some Workers Think So,” detailed the motivations of generic employees, focusing on financial and family drivers of their choice of workplace, but does not break down data by personality type or DSM diagnosis.

Before commenting on experiences relayed to me by the aforementioned subgroup of my patients, let us first look at the better publicized psychiatric fallout from the COVID-19 crisis. Centers for Disease Control and Prevention (CDC) 

 from late June 2020 state that 40% of the American population were facing COVID-related depression, anxiety, stress-related disorders, or substance use.

high-risk groups, noting that financial stressors, including epidemic-related job loss, along with limited savings to cushion the blow, increased an individual’s risk for mental health sequelae.

 about increasing drug and alcohol use are equally grim from a medical and mental health point of view, given that liquor sales skyrocketed during lockdown, as per several articles in the WSJ.

 Anonymous liquor store owners have said that demands for their stock during the epidemic rivals sales seen only during weeks between Christmas and New Year’s.

We can estimate the long-term mental and medical impact of alcohol overuse, even though many medical consequences of alcohol overuse do not surface for 20 years. The potentially lethal cardiovascular, oncological, as well as gastrointestinal consequences are not as obvious or immediate as motor vehicle accident-related deaths or fatal subdural bleeds from slip-and-fall accidents that occur while intoxicated. Yet those later sequelae are just as deadly in the long run, so much so that 

 is twice that of the better-publicized opioid-related mortality,with alcohol claiming over 95,000 lives per year,

 compared with 46,800 annual opioid overdoses.

Opiate overdoses have already exploded. If we extrapolate from data related to September 11, 2001, when 

 in Manhattan remained high long after posttraumatic stress disorder symptoms subsided,

 we can anticipate (but not guarantee) similar consequences from this epidemic.

Alarmist claims about projected increases in suicide hit the press, having borrowed data from CDC websites and embellished it with artistic license not appropriate to scientific studies. Some of the most ominous predictions have been refuted; after reading the fine print, we can see that these highly publicized numbers about suicide pertain to individuals who were contemplating suicide rather than to completed suicides. In response to those data, some British medical journals 

 readers that “supposition, however, is no replacement for evidence,” and that “the literature on the effect of COVID-19 on suicide should be interpreted with caution.”

Although reports of increased suicidal ideation since the start of the COVID-19 crisis were striking enough to enter the CDC logs, we must recall that suicidal ideation is not the same as attempted suicide, and that attempted suicide is not identical to completed suicide.

In addition, a New York City Health Department 

 “Mental Health in New York City: Impact of COVID-19 on Mental Health in New York City,” published in September 2020 and emailed widely in January 2021, offered even more 

 It dissected the data, breaking it down by race and ethnicity, and ferreted even more risk factors for anxiety and depression. It focused on the greater New York area, where most of my patients reside. Similar to the 

data, the 3 top drivers of psychological distress included “feeling cut off or distant from people,” “job loss or reduced hours,” and “overwhelming or above-average financial stress.” Interestingly, many individuals on the spectrum specifically prefer to be “distant from people,” although individuals with pure social anxiety disorder often lament their limitations in partaking in such social activities.

What do these data tell us about the socially phobic individuals who report less stress during the lockdown, but experience more stress when contemplating the possibility of a return to onsite work? Let me point out that although the data showed that 40% of the American population endorsed symptoms of depression, anxiety, or trauma during the shelter-in-place mandates and work-from-home policies, this is not the same as saying that 100% of the population is suffering similarly.

My clinical experience indicates that some individuals are benefiting from limits on social interactions; they prefer the work-at-home policies and appreciate convenient excuses to avoid after-work get-togethers and sit-down holiday dinners.

Admittedly, I cannot offer elegant statistics to rival numbers garnered from formal population-based quantitative studies. All I can share are anecdotal reports gleaned from my large private psychiatric practice, originally based in New York City, but now relocated offsite to upstate New York. Yet those anecdotal reports are impressive. Gainfully employed but socially phobic patients and those on the high end of the autism spectrum (who also tend to be debilitated by social anxiety) are doing better than baseline now that they are freed from the pressures of office politics, enforced personal interactions, and water cooler–style conversations.

In many instances, such individuals experienced an unexpected sense of relief, as well as a sense of accomplishment, after seeing that they could meet their work responsibilities even better without expending extra mental energy ruminating about social interactions, wondering if they said the right thing, and worrying about being forced to speak up in meetings. Having witnessed how much easier their lives can be without the usual social stresses, they identify a different source of anxiety: fear of forced return to the workplace.

Before proceeding, I must point out that the patients to whom I refer are actively and gainfully employed—and so they do not fall into the high-risk categories identified by the 

article. They did not experience the stressors, such as job loss or lack of savings, that predispose individuals to COVID-19–related psychological distress. Because they were working before the pandemic, they likely accrued savings that further buffer them from the financial stressors listed in the 

Recall that socially phobic individuals are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations.

And that is where we as psychiatrists can help. Selective serotonin reuptake inhibitors (SSRIs) and supportive therapy go only so far in ameliorating their symptoms and relieving their distress. Advocating for changing their external environment—while we change their internal environment through psychotropic medications and psychotherapy—can offer them so much more relief.

 accommodations that may allow them to continue to work from home even after the epidemic ends (with some caveats). Familiarizing ourselves with the Department of Labor website (

) will enable us to educate our patients and to direct them to standardized sources without offering legal advice that exceeds our clinical training or purview.

At a time when so many psychiatrists are concerned with climate change and its impact on mental health, should we not also concern ourselves with adapting workplaces to meet the needs of our patients? We can advocate for change, simply by following the laws that are already in place for such purposes.

 is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

1. Stamm S. Is a home office actually more productive? Some workers think so. 

https://www.wsj.com/articles/is-a-home-office-actually-more-productive-some-workers-think-so-11609563632

2. Centers for Disease Control and Prevention. Coronavirus disease 2019. Accessed February 10, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/index.html

3. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. 

4. Chaudhuri S. Coronavirus closed the bars. America stocked the liquor cabinet. 

https://www.wsj.com/articles/coronavirus-closed-the-bars-america-stocked-the-liquor-cabinet-11586511001

5. Jakab S. The WHO are a bunch of party poopers. 

https://www.wsj.com/articles/the-who-are-a-bunch-of-party-poopers-11587046692

6. Chaudhuri S. Online beer sales soar at brewers of Budweiser, Miller Lite. 

https://www.wsj.com/articles/online-beer-sales-drinking-at-home-boosts-budweiser-brewer-11603968729

7. Centers for Disease Control and Prevention. Deaths from excessive alcohol use in the US. Accessed February 15, 2021. 

https://www.cdc.gov/ALCOHOL/FEATURES/EXCESSIVE-ALCOHOL-DEATHS.HTML

8. Centers for Disease Control and Prevention. Drug overdose deaths. Accessed February 15, 2021. 

https://www.cdc.gov/drugoverdose/data/statedeaths.html

9.Packer S. Tele-teatime during the quarantine. 

https://www.psychiatrictimes.com/view/tele-teatime-during-quarantine

Trends in suicide during the covid-19 pandemic

. 2020;371:m4352. doi:10.1136/bmj.m4352.

11. New York City. Mental health in New York City: Impact of COVID-19 on mental health in New York City. September 2020. 

https://www1.nyc.gov/assets/doh/downloads/pdf/covid/covid-19-mental-health-impacts-hop.pdf

Patients who are report social phobia are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations. That is where psychiatrists can help.





The Other Side of the COVID-19 Crisis: The Silent, Socially Phobic Minority 

When thinking about education as it pertains to autism, it is imperative to consider what obstacles children and adolescents with autism spectrum disorder will face. Distance learning during the coronavirus disease 2019 (COVID-19) may present additional challenges. Psychiatrists are in the unique position to recognize the social, emotional, and developmental needs of these children. Psychiatrists can play a significant role in the coordination and implementation of multi-dimensional mental health care delivery systems across disciplines, including the pediatricians, parents, teachers and therapists.

Evidently autism is a lifelong condition, and the path to clinical improvement requires therapeutic and educational support. Among the assortment of educational barriers, the most prominent are alterations in sensory perception, behavioral inflexibility, and 

 Children with autism require a multimodal approach: specialized education planning, a great degree of structure (through predictable routines), visual schedules, and a dedicated learning environment to 

 Professionals with different expertise must work together to offer a nurturing environment for these children’s intellectual growth. Children with autism thrive and meet their academic goals with the assistance of special education teachers, speech therapists, and mental health counselors.

 Their educational requirements will also demand a lot of parental involvement and access to systems of care. For instance, extensive behavioral therapy for at least 25 hours a week is recommended for school-aged children with autism.

 The aim is to facilitate improvement in social and cognitive functioning, verbal and nonverbal communication, and to address maladaptive behavior.

Children and adolescents with autism face many challenges to obtaining quality education, and COVID-19 has raised these hurdles to 

 Since the start of the COVID-19 pandemic, many schools have transitioned to online learning modalities (eg, Zoom, Skype, Google Teach from Anywhere) to deliver education in children’s homes. The abrupt shift from in-person to distance learning may pose a difficult transition. Regulation of sensory needs, particularly visual and auditory processing, is quite difficult when learning is happening over a computer screen for 

 Children with autism are also accustomed to relying on a school’s structured schedule and the help of paraprofessionals to learn necessary social and academic skills. Behavioral inflexibility in children with autism entails resistance to change and insistence on a structured routine, so deviance from their schedule can cause extreme distress.

These children also have a strong attachment to certain individuals or places, and they may be preoccupied with unusual activities that are impossible because of COVID-19 regulations. Relationship development interventions are essential to mitigate social deficits and improve adaptation skills for functioning in a dynamic society. Unfortunately, given COVID-19 restrictions, maintaining the same level of structure and routine is, to say the least, a challenge, not only for these kids but also for their caregivers.

The unique circumstance of COVID-19 has required children with autism, their caretakers, and health care professionals to adapt in creative ways. Parents of children with autism find themselves in a position where they need to take on multiple roles, such as teachers, and physical, occupational, and speech therapists. This causes stress in the lives of both parents and their children.

Unlike classroom learning, distance learning requires a significant amount of effort from parents. Parents must supervise their children’s classes and are primarily responsible for setting a schedule for their schoolwork. Parents may struggle to manage the learning needs of their children, as the behavioral issues may be compounded by pandemic-associated lifestyle changes. For example, the frequency of aggressive behavior and tantrums may increase.

 Given these setbacks, parents may understandably worry that their children could fall behind in their developmental course.

It is important for the mental health care community, paraprofessionals, and caregivers/parents to collaborate and develop strategies to handle the complications inherent to remote learning. Although distance learning has made it difficult to access the specialized care and services they require, parents and caregivers can still create an enriching learning environment. Here are a few strategies that psychiatrists and other caregivers can suggest:

• Provide a structured environment at home, such as designating a particular table or room for online learning and a separate area for social activities. This may help with sensory adaptation and foster a 

• Set up visual daily and monthly schedules. This is an excellent way to incorporate routine into students’ lives.

• Incorporate frequent breaks into the schedule and use reminders to signify the end of 1 activity and the start of another.

• Equip play areas with familiar toys or objects to increase the overall familiarity of the students’ surroundings.

• Collaborate with skilled workers, professionals, and psychiatrists. It is crucial for parents to learn the best methods for satisfying the needs of students with autism.

• Maintain social connectivity with peers and professionals via an online platform. This can prevent the regression in these children’s social development.

Many autism societies and health care organizations have posted COVID-19 resources to guide care providers. Online resources also exist to support parents as they navigate the distance learning process. As individuals continue to be cautious and stay at home because of social distancing efforts, teachers, caregivers, and parents should work collectively to develop new methods to succeed even in these trying circumstances and provide the nurturing care that these children deserve.

is a fellow in the Department of Child and Adolescent Psychiatry, New York University Grossman School of Medicine.

is a medical intern at MS Ramaiah Medical College, Bangalore, India. The authors report no conflicts of interest concerning the subject matter of this article.

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

1. Robertson CE, Baron-Cohen S. Sensory perception in autism. 

2. Myers SM, Johnson CP; American Academy of Pediatrics Council on Children With Disabilities. Management of children with autism spectrum disorders. 

3. Yahya AS, Khawaja S. Supporting patients with autism during COVID-19. 

4. Mattard-Labrecque C, Ben Amor L, Couture MM. Children with autism and attention difficulties: a pilot study of the association between sensory, motor, and adaptive behaviors. 

5. Narzisi A. Handle the autism spectrum condition during coronavirus (COVID-19) stay at home period: ten tips for helping parents and caregivers of young children. 

Children with autism spectrum disorder have special educational needs, but with proper guidance they can flourish, even during a pandemic. 

How Psychiatrists Can Guide Distance Learning

My 18-year-old daughter has severe autism. She was doing relatively well at an 

 day school with home support, but as she grew older and hit puberty, with all the challenges that brings, things changed.

One evening, my daughter was sitting on the couch. Suddenly, she got up, forcefully hit herself in the head with her hands, ran upstairs into my room and thrust herself over my bed, banging her head into the mattress. Then she started chasing and trying to attack me. In fear, I locked myself in the bathroom. After what I perceived to be 5 minutes, I came out—only to find her drinking hand sanitizer. I removed it. She calmed down and went to the basement to play on her swing, laughing and giggling as if nothing ever happened. Her nose and mouth were bleeding, but she showed no signs of distress. That night, she fell asleep early and slept through the night, again as if nothing ever happened.

The next day, the dentist told me that my daughter had broken her frenulum. Had her hand been positioned slightly differently, she would have fractured her teeth. That is when I started to ask myself if I should be keeping her at home. Had a patient’s parent reported to me a similar experience with their child, I would have recommended 

 for the child’s safety, along with an applied behavior analysis program. After all, I am a psychiatrist, with advanced fellowship training in autism. I realized that I could not—and should not—treat myself and my child any differently.

I am no stranger to autism, its impact on the family as well as on the individual. My identical twin brothers also have autism. My brother banged his head so hard that he needed surgery, intravenous antibiotics, and 5 months of medical hospitalization. We were so relieved when a residential school accepted him. That was not a hard decision, given its antecedents. He has been doing well since, off medications for over 30 years, working and going on trips.

Typically, it upset me when parents rejected my recommendations for residential educational placement with applied behavior analysis. Some parents would not let go despite the dangers at home. While I always tried to be empathetic, sometimes I saw them as selfish because they did not put their child’s needs first. Yet with my daughter, it was different. I often second-guessed myself, wondering if I was doing it for myself or for my daughter, maybe choosing this because subconsciously I wanted a life of my own and had tired of watching every dime while paying for autism school tuition and home therapies.

“Was I exaggerating her behaviors?” I asked myself, wondering if I was inventing excuses to send her away. I worried that she would not understand that I planned to visit often. Maybe she would wonder if we would ever see one another again. I had nightmares about sending her away. Still, I knew I could not keep her safe at home.

One morning, my daughter bit the bus driver. Yes, the same daughter with the beautiful smile and giggles. Still unable to decide, I called a friend who works in mental health, requesting reassurance.

I kept resisting what I knew was the right decision, even after a board-certified behavior analyst evaluated her and assured me that this was the best decision available for bad circumstances. My self-doubt persisted. Was my concern about potential traumatic brain injury exaggerated, even unfounded? How could I, a parent, be objective with my own child? Yet when I showed a video to my daughter’s developmental pediatrician, she, too, agreed. How much more reassurance did I need?

While all this was transpiring, my black and blue marks from my daughter’s aggression remained. There were still more stories to tell. Once, when she was applying her deodorant, she started to squeeze me hard. I backed away—and she ate her deodorant. Her pica had been constant in the past. It had improved with applied behavior analysis, and now occurred only every few months. Yet even one-off behavior can be life-threatening, and I was helpless to stop her.

When the pandemic began, schools closed. Life became a nightmare. My husband had heart surgery. My daughter’s community habilitation worker quit. With no one to care for my daughter, I postponed my own doctors’ appointments. Without school, she regressed, staying up at night, giving herself bloody noses, attacking me and my husband, and running out of the house.

With my daughter’s school closed, I found myself providing most of the therapy, but I was alone, without the full crisis team available at school. When she once again attacked me while I was following the school directed curriculum, I was forced to lock myself in the bathroom out of fear. I did not want to activate 

 when New York (as well as other states) was in crisis mode, with limited resources and police who are not usually trained to handle this population.

During the pandemic, I could practice psychiatry only a few hours a week. One time, while evaluating a patient, my daughter bit me. While her teeth were in me, I cursed, for the first time ever on the job. I was very embarrassed. In a role reversal, the patient asked me if I were okay.

At the end of a session, a patient was annoyed with the background noise. I apologized and told her that my daughter has autism. Afterwards, I started my sessions with, “If you hear loud noises, I apologize in advance. My daughter has autism.”

I hired a sitter but sometimes even the sitter needed help in managing my daughter’s behaviors. Once she ran up the basement stairs, ahead of the sitter. I interrupted my session with a depressed patient to redirect her out of the kitchen, where she might eat soap or a banana peel. The patient started laughing. When I commented about her laughter, the patient seemed embarrassed and explained that she was not laughing at my daughter, but at what I said, “It’s good you can laugh,” I replied, “A lot of people with depression can’t.”

After I abruptly interrupted sessions due to self-injury or aggression on the part of my daughter, some patients empathized with me, saying, “It must be hard,” or “You have a lot of problems.” At the beginning of sessions, some patients would ask, “How is your daughter?” I would give some nonspecific yet truthful answer like, “She’s hanging in there, one day at a time,” and redirect to how the patient was doing. I found it very hard to focus on the job. For the first time I could remember, it took great effort to remain professional and patient with my patients. I had urges to say rude things. It was exceedingly difficult to serve my patients after my daughter had just attacked me, and after I had a night of disrupted sleep.

During my daughter’s 3 and a half months out of school, I lost 5 pounds and was extremely sleep deprived. There were times I was so unfocused, I put napkins in the refrigerator and even a metal pot in the microwave. Fortunately, I noticed the sparks before anything happened.

Yet there was a silver lining to COVID-19. Unlike her teachers, on some programs, I had felt frustrated with her slow progress, but then I discovered that she knew all the letters by sound and recognized a few words by sight. I taught her to request her favorite foods by handing me the word. I learned how to turn every activity of the day into a learning experience.

When I finally decided to place my daughter in residential care, I felt guilty for not spending more time with her before she left. Now, after COVID-19, I will never feel that way again. We have some great memories from our time at home, and she is happy in her new environment. In fact, she has adjusted better than I did. I now know that we, as psychiatrists, must not only recommend residential placement for safety, but we must also reassure guilt-ridden and self-doubting parents that they are acting in their child’s interests.

MD is a practicing psychiatrist in Queens, NY. She completed a fellowship in autism research and is the author of authored “Don’t Medicate–Educate! One Family, Three Cases of Autism, Safe Treatment for Dangerous Behavior.” More information can be found on her website 

What happens when a clinician has to give herself news she does not want to hear?

A Doctor, Her Daughter, and a Difficult Dilemma

Seclusion, the disciplinary practice in which a child is placed in a location that isolates them from peers and adults, has long been considered controversial.

 Seclusion emerged as a common practice within special education during the 1960s and 1970s and has, in more recent decades, increased in general education settings despite the lack of evidence that it is effective.

 In fact, seclusion has been associated with negative physical and psychological outcomes, including death, and children with disabilities and mental health needs are at increased risk for seclusion relative to their peers.

in collaboration with ProPublica, published a 

on the use of seclusion for children and youth in schools and special education settings across Illinois.

 The report revealed shocking abusive practices, including long-duration seclusions for young children, lack of adult oversight, and overly harsh discipline for minor infractions. As noted in the report, seclusion is banned in four states and restricted in sixteen others. Following the report, Illinois issued new guidelines and now bans this practice.

More recently, a group of Illinois congressional representatives issued a letter to the Secretary of Education asking her to ban all seclusions in educational settings nationwide. As noted in these reports and letters, there is no therapeutic rationale for long-duration seclusion, and there are many more viable and effective alternatives.

 disciplinary practices in schools are disproportionately applied to youth of color with significant disruption in their learning; often referred to as the school-to-prison pipeline.

and ProPublica, only 19 states have banned school seclusion, and such practices are not regulated by federal law.

 In this article, we discuss the reasons for the maintenance of abusive disciplinary practices with youth despite considerable evidence for more effective alternatives, suggest a renewed focus on reducing disparities and promoting equitable funding across communities, and share thoughts and implications for psychiatrists.

Harsh discipline with children-whether it is corporal punishment by parents or overly punitive practices in schools-has long been established as ineffective and counter-productive, yet it remains a common practice.

 Harsh disciplinary practices lead to high rates of childhood aggression and delinquency, with strong intergenerational transmission.

 at the Oregon Social Learning Institute first identified what they termed 

: escalating child misbehavior is met with escalating punitive practices by parents. They noted that the adult overuse of punishment is often a model for the child to use aggression to solve problems with peers or teachers. Their research led to the development of a generation of programs to teach parents and teachers alternative discipline practices.

Several decades of experience in urban schools in Philadelphia and Chicago provided our research team with more than enough anecdotal evidence that the coercive cycle was a well-established pattern, but empirical data were lacking to document the nature and extent of disciplinary practices. In collaboration with a principal at one Chicago Public School in which we were consulting, we collected and catalogued disciplinary records for all 3rd through 8th grade students (N = 314) for an entire school year.

We found that the coercive cycle was in place for some but not all students. Specifically, being disciplined was a deterrent for about 20% of students; after being disciplined in the fall, they did not receive any other discipline for the rest of the school year. In general, their infractions were minor, such as not wearing a school uniform or talking out in class, and the consequences less severe-detentions rather than expulsions. For them, the punishment accomplished its goal of discouraging misbehavior.

But for another quarter of the students, the findings were more troubling. Their infractions were more serious (eg, fighting, cursing) and the punishment more severe (expulsion rather than detention). Of even more concern, being disciplined led to increased disruptive behavior throughout the school year. As a group, these students were rated as highly aggressive by teachers and were less popular with their peers. Based on the escalation of their disruptive behavior, the consequences appeared to serve as a reward not a punishment. That is, for these students, being removed from the classroom may have been preferred over remaining in a classroom, which was supposed to be a negative experience for them. Teachers were also relieved with the removal of disruptive students from the classroom, because it allowed them to resume their teaching. Thus, for these students, the coercive cycle was fully entrenched (

Children with autism spectrum disorder comorbid with ADHD had especially high rates of harsh discipline.

 Reducing the use of parental harsh discipline was found to be especially important for preschool children with ADHD through reduced autonomic responding associated with anger management and emotional behaviors.

 A recent study of disciplinary practices in high schools and middle schools in Maryland noted high rates of suspension for students with disabilities. This was especially pronounced in low-achieving schools serving students in areas of lower socioeconomic status.

The processes supporting the coercive cycle are well established behavioral patterns that can be difficult to modify, and the stakes in psychiatric and special education facilities are even higher. In fact, following the ProPublica and 

report, the Illinois State Department of Education issued a statewide ban on seclusion in child psychiatric facilities only to lift the ban in favor of increased monitoring after programs indicated that without these procedures they would need to discharge their most aggressive youth.

 Clearly, the state was unprepared to accommodate these facilities to fully address the needs of these youth.

From a psychiatric public health perspective, this report and the subsequent responses highlight the urgent need to address the poor state of public education for our most vulnerable youth. It is understandable that legislators and advocates are looking to government officials to ban abusive practices, such as seclusion, but a focus only on what not to do will likely only push this problem further underground. It is not a lack of knowledge that is perpetuating these abusive practices, but a lack of willingness to fund programs, and staff, at levels needed to assure effective practices.

Some three decades ago, our research team consulted at a large state psychiatric hospital outside of Philadelphia and saw first-hand how staff shortages and lack of training led to abusive disciplinary practices.

 Young patients and patients of color were most likely to receive long seclusions, lasting between 4 and 5 hours-and the staff were unprepared for the more complex behavioral reward programs we recommended, such as increased privileges (eg, TV time, later bedtime) contingent on appropriate behavior. Sadly, this was highly similar to the findings in the most recent report from Illinois.

Similarly, for youth in special education, lack of adequate funding is a key factor in deteriorating services. A review of state funding of education from the nonpartisan Center on Budget and Policy Priorities noted steep cuts in spending on education for most states with staffing levels and teacher salaries being especially hard hit.

 It is no wonder that disparities in education remain a pernicious problem in the US-driving the growing income gap between rich and poor.

report is important in contributing to a national awareness of the deplorable state of public education in the US for our most vulnerable and needy children. Politicians and state government representatives who call for higher standards of care and greater accountability from education authorities are also to be commended. However, neither of these will effect meaningful change unless they are accompanied with dedicated funding for staffing, training in evidence-based education, and special education behavior management practices as well as organizational support for implementing and monitoring these practices.

There are numerous, easily accessible programs on effective disciplinary strategies focused on standardized classroom routines and use of praise and positive reinforcement as well as less severe consequences such as timeout and loss of privileges. However, they are not widely disseminated, especially in communities of poorer socioeconomic status.

 Online resources are becoming more prevalent and research is emerging that looks at factors that affect parent and teacher response.

report and the attention they have garnered can spur a long-needed alignment of knowledge and political will to break the coercive cycle to abusive disciplinary practices in schools. But given that much of this information has been known in principle if not in detail, it is likely that more direct advocacy is needed. Working together, psychiatry and its allied disciplines of psychology and social work have the knowledge and leverage to disseminate information on effective discipline to schools and parents. It may be difficult in a fee-based health care environment to find the time and resources that will impact communities, but even a little effort by each of us can go a long way. Children and their parents and teachers deserve no less.

To read “The Quiet Rooms” published by ProPublica and the 

https://graphics.chicagotribune.com/illinois-seclusion/index.html

. Share your comments on this article and other pieces by emailing 

 is Professor of Psychiatry and Psychology; Director, Institute for Juvenile Research; and Director, Community Engagement and Collaboration Center for Clinical Translational Science, University of Illinois, Chicago. 

 is Assistant Professor of Psychology in Psychiatry, Institute for Juvenile Research, Department of Psychiatry; and Director of Inclusion Initiatives, Office of the Vice President for Diversity, University of Illinois, Chicago. The authors report no conflicts of interest concerning the subject matter of this article.

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14. Atkins MS, McKay MM, Frazier SL, et al. Suspensions and detentions in an inner-city school: punishment or reward? 

15. Flouri E, Midouhas E, Charman T, et al. Poverty and the growth of emotional and conduct problems in children with autism with and without comorbid ADHD. 

16. Bell Z, Shader T, Webster-Stratton C, et al. Improvements in negative parenting mediate changes in children’s autonomic responding following a preschool intervention for ADHD. 

17. Camancho KA, Krezmien MP. Individual-and school-level factors contributing to disproportionate suspension rates: a multilevel analysis of one state. 

18. Illinois State Board of Education. ISBE Amends Emergency Rules with Advocate Feedback. December 4, 2019.

19. Atkins MS, Ricciuti A. The disproportionate use of seclusion in a childrens psychiatric state hospital. 

20. Leachman M, Masterson K, Figueroa E, et al. A Punishing Decade for School Funding. Center on Budget and Policy Priorities. November 29, 2017.

21. The Heichinger Report Contributor. The growing achievement gap: income inequality is exacerbating the gap between rich and poor school children. 

22. Atkins MS, Cappella E, Shernoff ES, et al. Schooling and children’s mental health: realigning resources to reduce disparities and advance public health. 

23. Lakind D, Atkins MS. Promoting positive parenting for families in poverty: new directions for improved reach and engagement. 

24. Marquez B, Vincent C, Marquez J, et al. Opportunities and challenges in training elementary school teachers in classroom management: initial results fromclassroom management in action, an online professional development program.

25. Baker S, Sanders Mr, Morawska A. Who uses online parenting support? A cross-sectional survey exploring Australian parents’ internet use for parenting. 

The authors discuss abusive disciplinary practices that continue to this day despite considerable evidence to the contrary and share thoughts and implications for psychiatrists.

The Coercive Cycle: A School to Prison Pipeline?

I always wanted to be a doctor. I don’t know why. There were no doctors in the family.

My dad was a machinist at a machine tool company. Both Dad and Mom had only an 8th-grade education. But what they lacked in reading, writing, and arithmetic they made up for in determination, hard work, and innate wisdom.

Dad excelled at his craft and was the natural choice for promotion to supervisor of the machine shop when the incumbent retired. But the company told him it just wouldn’t look right to have a person with only an 8th-grade education in that important position on the company roster. So they bypassed him.

Dad was disappointed, of course. But he told me: “Darold, get that piece of paper. It’s your ticket to the future. I don’t care if you want to be a plumber, minister, or doctor. Get that piece of paper.”

So I did. Dad was right. That piece of paper served me well. I got into University of Wisconsin School of Medicine after 3 years of pre-med. I then completed a rotating internship (remember those?) at Sacred Heart General Hospital in Eugene, Oregon.

 offered a “career plan” for psychiatric residents at that time. If one agreed to serve 2 years at one of Wisconsin’s mental hospitals or developmental disability centers, they would pay a living wage for 3 years of training.

My assignment was to Winnebago Mental Health Institute, which had 800 patients. About 30 patients were under age 18, so I had the opportunity to start a children’s unit.  Most of the children were autistic or had other developmental disabilities.

, who first described Early Infantile Autism in 1943, inspired my interest in autism. He often visited his son in Madison, Wisconsin, and spent some time teaching at the medical school. He was a grand teacher. What I learned from him provided the tips and pearls I needed when I started the children’s unit at Winnebago.

Four children in the unit caught my eye. One lad had memorized the bus system of Milwaukee. If you told him the time of day, he could tell which bus was rounding what corner in the city. Another could rapidly assemble a 200-piece jigsaw puzzle 

A third boy was an expert on what happened on each day in history. When I made my morning rounds, he would quiz me. I tried to bone up the night before (and that was in the day of the encyclopedia), but I could never top his list. And then there was Billy, who made free throws. He would hold the ball in exactly the same way, put his feet in exactly the same position, and since the free throw has a fixed trajectory, his free throws always went in.

So I developed a special interest in "savant syndrome," a rare but remarkable condition in which persons with some underlying disability-often but not always autism-have some “Island of Genius,” or ability that stands in marked contrast to overall limitations. I have written two books on this condition: 

Extraordinary People: Understanding Savant Syndrome 

Islands of Genius: The Bountiful Mind of the Autistic, Acquired and Sudden Savant 

I first met a "savant" in 1962 and have now collected hundreds of cases of congenital, acquired, and sudden savants. Each of these categories is described or seen on video on a website I have maintained through the 

. To preserve, share, and distribute my vast collection of books, papers, media accounts, and videos on savant syndrome, Agnesian Health Care, SSM Health, established the Treffert Center, which can be accessed at 

Of course, “autistic savant” became a household term following the movie 

 in which Dustin Hoffman portrayed Raymond Babbitt so realistically. I was a consultant to that movie and sought to ensure that it be accurate, with respect to real-life savant skills, and that the characters be sensitively portrayed.

My first career opportunity was serendipitous. The next opportunity came when the Superintendent of Winnebago Mental Health Institute decided to leave that post and move to Hawaii. I was asked if I would serve as interim Superintendent. I liked administrative psychiatry and served 15 years in that capacity. Later in my career I headed up a community mental health center for 12 years. And I completed the last days of formal clinical practice in private practice.

I didn’t plan each of those moves, but psychiatry presents a wealth of opportunities and it is prudent to be open to them. Presently, I am Research Director at the Treffert Center. I began my career surrounded by children. Now here I am again surrounded by the welcome sounds of children in the Treffert Academy, a strength-based, integrated education and treatment school for all children, some with developmental disorders.

Dad excelled at his craft and was the natural choice for promotion to supervisor of the machine shop when the incumbent retired. But the company told him it just wouldn’t "look right" to have a person with only an 8th-grade education.

Autism

The Other Side of the COVID-19 Crisis: The Silent, Socially Phobic Minority

How Psychiatrists Can Guide Distance Learning

A Doctor, Her Daughter, and a Difficult Dilemma

The Coercive Cycle: A School to Prison Pipeline?

Get That Piece of Paper

High Rates of Autistic Symptoms Found in Patients With Eating Disorders

Recognizing and Treating Comorbid Psychiatric Disorders in People With Autism

Trouble in Paradise: Carbon-Fuel Air Pollution Linked to Disorders Across the Lifespan

ECT for Self-Injurious Behavior in Autism: A New Indication

Asperger Disorder: Gone But Not Forgotten