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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.

1. Ryan JB, Peterson RL, Tetreault G, et al. Reducing the use of seclusion and restraint in a day school program. In Nunno MA, Day DM, Bullard LB, Eds. Examining the Safety of High-Risk Interventions for Children and Young People. New York, NY: Child Welfare League of America; 2007: 201-216.

2. Zaccaro DE. Unregulated Untrained, and Unaware: Restraint and Seclusion Practices in Educational Settings [dissertation]. Cedar Falls, IA: University of Northern Iowa; 2014.

3. National Disability Rights Network. School Is Not Supposed to Hurt: Investigative Report on Abusive Restraint and Seclusion in Schools. January 2009.

4. Smith Richards J, Cohen JS, Chavis L. The Quiet Rooms: Children Are Being Locked Away, Alone and Terrified, in Schools Across Illinois. 

5. Illinois State Board of Education. State Board of Education to Take Emergency Action to End the Use of Isolated Seclusion in Illinois Schools. November 20, 2019.

Encouraging alternatives to seclusion, restraint, and reliance on PRN drugs in a public psychiatric hospital

7. Skiba RJ, Arredondo MI, Williams NT. More than a metaphor: the contribution of exclusionary discipline to a school-to-prison pipeline. 

8. Lansford JE, Dodge KA. Cultural norms for adult corporal punishment of children and societal rates of endorsement and use of violence. 

9. Weiss B, Dodge KA, Bates JE, Pettit GS. Some consequences of early harsh discipline: child aggression and a maladaptive social information processing style. 

10. Bailey JA, Hill KG, Oesterle S, Hawkins JD. Parenting practices and problem behavior across three generations: monitoring, harsh discipline, and drug use in the intergenerational transmission of externalizing behavior. 

11. Patterson GR, Dishion TJ, Bank L. Family interaction: a process model of deviancy training. 

12. Sandler IN, Schoenfelder EN, Wolchik SA, Mackinnon DP. Long-term impact of prevention programs to promote effective parenting: lasting effects but uncertain processes. 

13. Epstein M, Atkins M, Cullinan D, et al. Reducing behavior problems in the elementary school classroom: a practice guide (NCEE #2008-012). US Department of Education. September 2008.

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.

Lesson: When you have that piece of paper, be open to all sorts of career options as they present themselves, as they surely will.

 Whenever I speak to students at whatever level, I encourage them to get that piece of paper and I contribute to scholarships whenever I can.

Recently, I was asked to speak to a group of 4th graders about my lifework studying autism and savant syndrome. I was scared stiff. What do you say to a group of 4th graders? I usually speak to adults.

But the grade schoolers were well prepared, and the questions were numerous and sophisticated. “Why are there more male savants than female?” “How come so many savants know how to calendar calculate?” “Might there be some savant abilities in all of us?”

At the end of the lecture a little boy and girl came up to ask some more questions. “I want to be a neuroscientist when I grow up,” Johnny said.

I have had many satisfying moments in my career. But the crowning moment will be when Johnny and Jane walk across that stage to get their graduate certificates-that “piece of paper”-that will enable them to carry on the work I have begun and take us further than we have ever been in fully understanding both the brain and human potential.

When that happens, I would like to think my little lecture might have had some motivating effect for Johnny and Jane to get that piece of paper. That’s why I lecture frequently to young people.

 is Research Director at the Treffert Center, Agnesian HealthCare in Fond du Lac, WI. Now semi-retired, he served as Clinical Professor at the University of Wisconsin School of Medicine and Public Health and the University of Wisconsin-Milwaukee.

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.

Get That Piece of Paper

What is the link between restrictive anorexia, anorexia nervosa, and binge eating disorder and ASD? This study sheds some light.

High Rates of Autistic Symptoms Found in Patients With Eating Disorders

The Centers for Disease Control and Prevention estimates that autism affects 1 in every 59 children in the US.

 While the core features of autism impair functioning, a significant source of further impairment is comorbid psychiatric disorders. People with autism spectrum disorder (ASD) are more likely than the general population to have comorbid psychiatric disorders. Although prevalence rates vary widely, converging evidence suggests that anxiety disorders and ADHD are most prevalent.

Numerous factors contribute to the increased risk for comorbid psychiatric disorders. People with autism are at higher risk of being bullied and are more likely to experience adverse life events, which can increase stress and risk for depression and anxiety. Cognitive rigidity, problems with emotion regulation, and intolerance of uncertainty associated with ASD can predispose this population to higher levels of anxiety and depression.

 Emotional regulation deficits may be a transdiagnostic phenomenon that underlies features of ASD as well as anxiety and other psychiatric comorbidities.

The Autism Comorbidity Interview (ACI) is a semi-structured interview that utilizes the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) with adaptation to increase validity in the ASD population. Additional screening questions and coding options were added to the ACI to help distinguish core features of ASD from features of other psychiatric disorders.

The ACI was used to assess psychiatric comorbidity in 109 children with ASD aged 5 to 17 years.

 Findings indicate that 72% of the children had at least one additional DSM-IV psychiatric diagnosis. Anxiety disorders were most common, followed by ADHD (

Assessment of comorbid psychiatric disorders

Screening instruments designed for psychiatric conditions in the general population may not adequately differentiate features of ASD and can result in overdiagnosis. However, there are several validated disorder-specific tools that have been specifically developed to assess for comorbid disorders in children and adults with ASD (

). Features of ASD can appear to overlap with symptoms of other conditions making it difficult to distinguish symptoms that relate to the core features of ASD versus symptoms of other psychiatric disorders (

General considerations for assessing psychiatric comorbidity in ASD

 It is important to establish an individual’s baseline for when he or she has functioned best. For psychiatric conditions that are episodic (eg, mood disorders) or those that appear later in development (eg, OCD, psychosis), it is important to distinguish baseline behaviors and functioning from distinct changes in symptoms that are expected with the onset of a co-occurring psychiatric condition.

 Assess for medical problems that can exacerbate emotional and behavioral symptoms, particularly in less verbal people.

 Some genetic syndromes are known to be associated with psychiatric conditions and behavioral phenotypes. This can help with more targeted screening (eg, fragile X syndrome has a higher prevalence of anxiety and ADHD, Williams syndrome has a higher prevalence of anxiety, and 22q11 deletion syndrome is associated with higher prevalence of psychosis).

4) Consider symptoms in the context of developmental level.

 Comorbid conditions should be considered if there are symptoms that are beyond what would be expected for an individual’s mental age and developmental level.

Using findings from their meta-analysis, vanSteensel and colleagues

 estimated that 40% of youth with ASD have a comorbid anxiety disorder. Risk factors for developing anxiety that are prevalent in ASD include social skill deficits, sensory sensitivity, cognitive rigidity, heightened physiological arousal, and difficulties regulating stress.

 Specific phobia tends to have an onset in childhood. In most cases the phenomenology of specific phobia in ASD tends to be similar to typically developing youth. However, people with developmental disabilities may also develop fears to unusual objects or situations, such as elevators, vacuum cleaners, etc.

Common phobias found in youth with ASD include loud noises, needles, and crowds. Sensory sensitivities can contribute to specific fears in autism, some of which may not rise to the level of meeting criteria for specific phobia but can contribute to impairment. For example, anxiety about eating food due to food textures, avoidance of clothing due to tactile sensitivity, or fear of loud objects such as vacuums and hairdryers due to noise sensitivity.

 Worry related to intense preoccupations, schedules, and environmental changes may be atypical features of anxiety that are important to recognize and ask patients about. Some of these features are captured by Kerns’s

 summation that they represent an “intolerance of uncertainty,” which can mark atypical anxiety in ASD.

Anxiety can present as perseverative questioning and reassurance seeking about an anticipated event or other worry. Repetitive questions used to obtain more information about a restricted interest should be distinguished from questions that are triggered by anxiety. People with ASD can have difficulty verbalizing internal states of anxiety or triggers for anxiety. For those who are non-communicative, an anxiety disorder may have to be considered by inference based on observation, such as persistent resistance to entering crowded rooms.

 Repetitive behaviors and restricted interests in ASD can be difficult to distinguish from the compulsions and obsessions of OCD. In OCD, obsessions are recurrent, intrusive thoughts that are distressing, and compulsive behaviors in OCD are bothersome, unwanted, and serve the function of attempting to alleviate the obsessional content.

Repetitive behaviors in ASD (eg, lining up objects, following the same routine, watching the same video) are generally a preferred or comforting activity, although they can lead to problematic behaviors or irritability when the person is interrupted or needs to stop. In addition, the most common forms of compulsions in OCD: hand washing, cleaning, making things “just right” are distinct from the typical repetitive behaviors of ASD, such as hand flapping, body rocking, and finger flicking.

People with ASD can have difficulty articulating obsessive thoughts and describing whether a behavior is aimed at reducing anxiety. The ACI adapted the criteria for OCD to allow caregivers to infer the mental experiences of people who exhibit compulsive behaviors. For example, caregivers could be asked if a compulsive behavior appeared to be aimed at reducing anxiety or linked to recurrent thoughts. Using this criteria Leyfer and colleagues

 found that 37% of their sample met criteria of OCD. In a different study by Simonoff and colleagues,

 the assessment tool did not allow for caregivers to make this inference and the prevalence of OCD was estimated at 8.2%.

 Diagnosis of social anxiety in ASD requires that a person with ASD is avoiding social interaction due to a fear of potential negative outcome rather than just a lack of interest in social interaction, which is a common core feature of ASD. In older higher-functioning youth social anxiety can develop as awareness of differences from peers increases.

ADHD is a common co-occurring condition with ASD and as such DSM-5 no longer prohibits ADHD to be diagnosed with ASD. Diagnosis of co-occurring ADHD can be challenging because symptoms of inattention, executive functioning problems, and social cognitive deficits are common in both conditions. It is important to distinguish features of inattention and impulsivity that may be inherent in ASD, such as distractibility related to a special interest, sensory seeking behaviors, or processing problems, from those that warrant an additional diagnosis of ADHD in children with ASD. The hyperactive-impulsive subtype of ADHD can also manifest in people with ASD and is best assessed in the context of the youth’s developmental age, expected activity level, and environmental demands.

Diagnosis of depression in neurotypical youth typically relies on self-report of mood symptoms such as feelings of sadness, hopelessness, or decreased self-esteem. Describing these internal states can be difficult for many people with ASD, particularly those with limited verbal skills.

 developed a framework for assessment of depression in ASD. For people with limited verbal skills or difficulties verbalizing feelings, increased self-injurious behavior, decreased self-care, labile moods, decreased interest in special interests, and regression of skills were observable behaviors associated with depression. For verbal youth with ASD, insight into ASD symptoms and their impact on functioning, awareness of being teased or being different from peers, social rejection, and low self-efficacy were risk factors for depression.

While their co-occurrence is uncommon, autism and psychosis have some symptom overlap, which can raise diagnostic questions. Pragmatic language deficits in ASD can include abrupt changes in topic, failure to provide context, and tangential comments, which can contribute to what appears to be a disorganized quality of language and thought process. When people with ASD are under stress they can have more disorganized and tangential speech, which is typically attributable to anxiety, problems with cognitive control, and pragmatic language deficits rather than underlying psychosis.

Moreover, people with ASD may use idiosyncratic language or scripted phrases from favorite movies or songs that appear out of context to the listener and therefore may sound disorganized or delusional. Strong convictions and overvalued ideas about their special interests may seem delusional. Difficulties with theory of mind and understanding the intentions of others may lead to distrust and paranoia but are best understood as the downstream effects of ASD core deficits, rather than a co-occurring psychosis.

There are currently no validated measures for assessing psychosis in ASD. Taking a detailed developmental history is key to distinguishing features of these two conditions. When psychosis occurs in ASD, the onset of psychotic symptoms is typically in adolescence or early adulthood and is associated with a change in functioning from baseline. Symptoms such as restricted affect, repetitive behaviors, tendency to disorganized speech when under stress, self-talk, or magical thinking, which have been chronic and present from a young age are more likely to be consistent with ASD rather than psychosis.

When baseline restricted interests become more morbid, illogical, and held with greater conviction with loss of reality testing, this may be more consistent delusional thought content, which may warrant an additional psychosis diagnosis. Larson and colleagues9 found that when psychosis co-occurs with ASD, the signs and symptoms of psychosis tended to be more transient and of shorter duration. As a result, the researchers noted that there tends to be a higher prevalence of psychotic disorder NOS (from DSM IV) diagnoses compared with schizophrenia diagnoses in part because of not meeting the duration of symptoms requirement.

Catatonic symptoms can develop in people with ASD with age of onset typically in adolescence.

 The occurrence of catatonia in autism is
	rare, but it is important to recognize given the benefit of early treatment and risk for life-threatening complications in severe cases. Diagnosis of catatonia in ASD can be challenging because echolalia, mutism, and stereotypic movements are common in both conditions.

Onset of catatonic symptoms in ASD may be gradual and in its early stages can present with a regression in self-care skills, reduction in speech, and difficulties initiating tasks. New onset of movement problems such as getting stuck part way through an action, difficulty initiating movements, immobility, increase in repetitive behaviors, difficulty crossing thresholds, and holding postures should raise suspicion for catatonia. Repetitive behaviors such as stereotypic movements and echolalia should not be counted toward a separate diagnosis of catatonia if they are consistent with an individual’s baseline symptoms of ASD.

Treatment of comorbid psychiatric conditions in ASD warrants a multimodal approach with contributions from caretaker education (applied behavioral analysis); psychotherapy; pharmacology; sensory, speech, and language interventions; and other disciplines depending on the individual’s history and presentation. Although a review of all of these modalities is beyond the scope of this article, some of the evidence and resources for CBT and pharmacotherapy for psychiatric comorbidity in ASD follow.

 CBT has been shown to reduce anxiety in children with ASD and anxiety disorders. Effective modifications to traditional CBT for youth with ASD have included increased parent involvement to promote generalization, incorporation of visual aids, making sessions highly structured and predictable, increased practice of skills, and explicit teaching of social skills as part of the therapy.

 Use of the child’s restricted interests can make the therapy more salient, help explain therapeutic concepts, create concrete metaphors, and reinforce participation.

ASD-specific CBT programs for anxiety include Multimodal Anxiety and Social Skills Intervention (MASSI), Face Your Fears, and Behavioral Interventions for Anxiety in Children With Autism (BIACA). Programs targeting executive functioning, mindfulness, and emotion regulation have also been found to reduce anxiety.

Pharmacological interventions. There are currently no medications for the core symptoms of ASD. Pharmacologic interventions for comorbid psychiatric conditions may help to alleviate associated symptoms and allow better engagement for the individual in educational and psychosocial treatments.

While the core features of autism impair functioning, a significant source of further impairment is comorbid psychiatric disorders.

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