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Rashmi Parmar, MD, gives an overview on autism. Examples of signs and symptoms in children include trouble having a back-and-forth conversation, difficulty establishing eye contact, and difficulty reading facial expressions.

is a double board-certified adult and child psychiatrist with Community Psychiatry based in Newark, CA. She earned her medical degree at Terna Medical College & Hospital in Mumbai, India.

More than 3.5 million Americans have Autism Spectrum Disorder. How can you recognize the signs in children? 

Common Signs and Symptoms of Autism Spectrum Disorder in Children

 and autism spectrum disorders is in its infancy, there has been much controversy and confusion. Over the years, more patients and their families are seeking guidance from doctors on using cannabis to alleviate symptoms. From preventing seizures to calming aggression, a slow trickle of research is suggesting that cannabidiol (CBD), a component of cannabis, may be the wonder drug families have been searching for. But does it hold up to this standard? Should we be recommending it to patients? How do we weigh the benefits and the risks?

Unfortunately, many clinicians lack adequate training on the subject, making them unprepared to have a meaningful discussion with patients and families. Efforts to advance research have been limited for technical and logistical reasons, often leaving doctors with just as many questions as patients.

is a genus of flowering plants belonging to the family Cannabaceae that includes 3 species: cannabis sativa, indica, and ruderalis. Marijuana specifically refers to the parts of the cannabis plant that contains high amounts of delta-9-tetrahydrocannabinol (THC). Medicinal use of the cannabis plant dates back thousands of years in cultures all around the world. Today, it is used to treat an assortment of conditions, such as arthritis, cancer, HIV/AIDS, glaucoma, seizures, and more.

Used recreationally, it produces a high or mind-altering effect when smoked or consumed. It is also used therapeutically. The National Institute on Drug Abuse 

 as “using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions.”

The plant produces more than 500 different chemical substances. These include 100 unique cannabinoids, which bind to the CB1 and CB2 receptors in the body’s endocannabinoid system. CB1 receptors are more common in the central and peripheral neurons, while CB2 receptors are expressed only in peripheral tissues, predominating the immune system.

THC and CBD are 2 cannabinoids found in cannabis that have particular clinical importance.

In medical applications, THC is typically used to relieve pain, nausea, insomnia, and poor appetite. THC is a partial agonist of the CB1 and CB2 receptors.

, which is why it is included in so many recreational marijuana products.

CBD is less controversial than THC because it does not produce mind-altering or euphoric effects. It has low affinity for CB1/CB2, acting as an antagonist.

 It affects various receptor systems in the body (TRPV1, GPR55, PPAR.) Of note is its agonism on the 5HT1A (serotonin) receptor at high concentrations to help with anxiety, sleep, pain perception, and nausea.

 It also appears to be a partial dopamine receptor agonist, pointing toward its possible antipsychotic properties. Additionally, CBD appears to influence the glutamate-GABA system.

Endocannabinoids are naturally occurring lipid mediators in the body that bind to the cannabinoid receptors. Unlike other neurotransmitters, they are produced on demand in the body and are quickly inactivated. The most common ones include: N-arachidonoylethanolamine (anandamide), 2-arachidonylglycerol (2-AG), and 2-arachidonylglyceryl ether.

Anandamide, also known as the “bliss molecule,” is currently one of the most-studied endocannabinoids.

 The cannabinoid receptor system has a very complex role in the body, which includes regulation of cell function, maintenance of homeostasis, motor coordination (basal ganglia), brain reward system, stress response, memory function (hippocampus), appetite, modulation of pain, and reduction of inflammation. 

Anandamide causes inhibition of the release of neurotransmitters such as glutamate and gamma aminobutyric acid (GABA). It also affects norepinephrine, dopamine, serotonin, histamine, prostaglandins and opioids.

 An imbalance in the GABA and glutamate system is often linked with 

Autism spectrum disorder (ASD) is a neurodevelopmental disability characterized by impairment in 3 major domains: social interaction, communication, and behavior patterns. It is called a spectrum disorder because it has a broad range of severity and symptom type. These usually appear within the first few years of life, although it can be diagnosed at any age.

In 2016, 1 in 54 children by the age of 8 was diagnosed with ASD, according to 

Centers for Disease Control and Prevention statistics

. This was a 10% increase over 2014, when the estimate was 1 in 59. Boys are 4 times more likely than girls to be diagnosed.

The causes of autism are not clearly understood. It is a complex disorder thought to be multifactorial in origin, involving genetic and environmental factors.

 It is associated with several conditions, such as Fragile X, Rett syndrome, tuberous sclerosis, phenylketonuria, and certain genetic conditions involving the deletion or duplication of chromosomes. Additionally, roughly 20% to 25% of individuals with autism are diagnosed with epilepsy at some point during their lives. Intellectual disability is also highly prevalent in autism, and there is a close association with seizure risk in autistic individuals.

Environmental factors being explored by research include viral infections, air pollutants, dietary factors, medications, and perinatal complications. Other common risk factors include children born to older parents, siblings of affected children (especially in the case of identical twins), and a family history of autism.

There are no medications that address autism’s core symptoms. Existing medications are used to target comorbid symptoms such as anxiety or mood symptoms and aggressive behavior. But these may not be very effective and often cause several side effects, limiting their use.

With autism cases on the rise, the need for effective treatments is rising too. Treatments in childhood carry special risks and potential rewards. Because a child’s brain is still developing, it is a good opportunity to make significant changes, but for the same reason, it is a dangerous time to experiment with certain compounds like THC and cannabis. Many of us have encountered desperate families who have found traditional treatments inadequate or resulting in undesirable side effects. At their wit’s end, they are willing to try just about anything. By not approaching the topic, patients and families may seek unsubstantiated advice on the Internet, leading them to use substandard and potentially dangerous products in an unregulated market.

Today, cannabis is easily accessible and popular with millions of Americans, but as noted, cannabis can be a mixture of many things. While the federal government considers cannabis a Schedule I drug, it has been legalized in 33 states and Washington, DC. Meanwhile, CBD is a schedule 5, the lowest degree of regulation by the US Food and Drug Administration. As a treatment for autism, cannabis has been prescribed in 14 states since 2019, according to the 

Whether we accept cannabis as a psychiatric treatment or not, our patients and their families are curious and interested in learning about all options. That is why it is vital for us as psychiatrists to educate ourselves on the use of cannabis to treat autism spectrum disorder (ASD), recognizing that the both the risks and benefits of use in ASD are indirect and insufficient. This might be the only way we can guide our patients to weigh all the facts before making a treatment choice.

Research on cannabis’ impact on autism is still very much in its infancy, but there are several important studies to consider, with more on the way. In a 2018 Stanford University study, anandamide concentration was significantly lower in children with ASD as compared to controls.

 Research studies have suggested that anandamide produces effects similar to, but less intense than, those associated with THC.

 Because of this similarity, researchers theorize THC has therapeutic potential in the treatment of autism.

Another study in 2013 found an increased expression of CB2 receptors in peripheral blood mononuclear cells in autistic children, suggesting an imbalance in the endocannabinoid system.

 Oxytocin is a neuropeptide crucial for social behavior, and studies indicate the oxytocin-driven anandamide signaling system may be defective in autism patients, leading researchers to theorize whether CBD can correct this.

Terpenoids are aromatic compounds present in the cannabis plant that give each strain its unique smell. Cannabinoids and terpenoids are thought to interact with each other as well as the brain in an entourage effect to produce synergistic results. This effect potentially increases the therapeutic value and tames the mind-altering effects of THC in a product. Similarly, there is some evidence proposing that the simultaneous use of THC and CBD is more effective than either alone. While still theoretical, it explains why both are often used together in medical applications.

 Further, the ratio of THC to CBD in a preparation determines the fine balance between its therapeutic use and mind-altering effects.

Epidiolex is the first CBD prescription approved by the US Food and Drug Administration (FDA) in 2018 to treat seizures associated with Lennox-Gastaut syndrome (LGS), Dravet syndrome (DS), and tuberous sclerosis (TS) in patients as young as 1 year old. It does not contain THC. This approval was based on 3 double-blind randomized controlled trials (RCT) and an open label extension study for LGS and DS, and one RCT for TS, all with 

 About 25% of children with treatment-resistant epilepsy have comorbid ASD. Both LGS and DS have been commonly linked to ASD.

It is important to note that medical cannabis has its own significant side effects 

 found that persistent users of cannabis had reduced neuropsychological functioning, with adolescent onset users experiencing greater decline in IQ and executive functioning.

 These effects did not reverse fully on stopping cannabis use for one year or more, suggesting it has potential neurotoxic effects.

cannabis use in adolescence can significantly increase the risk of developing psychotic symptoms

 and persistent use can precipitate psychotic disorders in later life.

 Studies have also shown that cannabis use and the development of psychosis in adolescents is dose-dependent, with poorer outcomes associated with an earlier age and higher frequency of use.

One 2015 to 2017 study conducted in Israel sought to gauge the safety and efficacy of cannabis.

 It observed 188 autism patients, most of whom were treated with an oil containing 30% CBD and 1.5% THC. It was not placebo controlled. After 6 months of treatment, parameters of activities of daily living, mood, and quality of life were assessed. It found that 30.1% of patients reported significant improvement, 53.7% moderate and 6.4% slight improvement, while 8.6% experienced no change to their condition. About 25% of self-reporting patients experienced at least 1 side effect from the treatment, the most common of which was restlessness. The study concluded that CBD and THC in autism patients appeared to be well-tolerated, safe, and effective.

In 2018, a study conducted at the Shaare Zedek Medical Center assessed the effect of a whole plant cannabis extract (20:1 CBD:THC ratio) on 60 autistic children with severe behavioral problems.

 Parents reported that 61% of behavioral symptoms in patients had either “much improved” or “very much improved,” 39% of children experienced improved anxiety level, and 47% improved in communication. Additionally, 24% of children were able to stop taking medication, 30% received either lower dose or fewer medications, while 8% had to increase medication intake. The incidence of side effects and adverse effects was quite high, reported by 57 parents. Common side effects included hypervigilance leading to sleeping difficulty (14%), irritability (9%), loss of appetite (9%), and restlessness (9%).

In another Israeli study published in 2019, 53 children with autism were given a 20:1 ratio CBD to THC dose for a median duration of 66 days in order to study its effect on comorbid symptoms with ASD.

 Symptoms were assessed every 2 weeks through phone call interviews with parents. Changes in individual symptoms cohorts were compared to available data from published studies. Of note, significant improvement was noted in self-injury and rage attacks (67.6%), hyperactivity symptoms (68.4%), sleep problems (71.4%), and anxiety (47.1%) within the groups of patients reporting these symptoms. The overall improvement in ASD comorbidities was calculated to be 74%. Common side effects included somnolence and reduced appetite.

It is important to note, however, that the aforementioned studies are limited because they were observational studies conducted without a placebo control group for comparison. Additionally, results were based on parental reports, which may have been heavily influenced by expectations, thus undermining results.

Adi Aran, MD, MSc, PhD, the Shaare Zedek study’s

 lead author, recently published a double-blinded, randomized placebo-controlled trial in February 2021 to study the role of cannabis in autism further.

 The study used 2 oral cannabinoid solutions (whole plant extract and purified forms of cannabis) with a 20:1 CBD to THC ratio along with a placebo. The purpose was to assess behavioral problems in 150 children and youth with autism with a unique crossover design that included 2 phases of 12 weeks, separated by a 4-week washout phase. It showed mixed results with no difference in one of the primary and secondary outcomes among the groups.

The study assigned 2 primary outcome measures to assess behavioral problems: the Home Situation Questionnaire-ASD (HSQ-ASD) and the Clinical Global Impression-Improvement scale, with anchor points related to behavioral difficulties (CG-I). Secondary outcomes were measured by the Social Responsiveness Scale-second edition (SRS-2,) the Autism Parenting Stress Index (APSI) and modified Liverpool Adverse Events Profile. There was no difference in the total score of HSQ-ASD and APSI between the groups. However, disruptive behavior assessed by CGI-I scale was “much” or “very much” improved in 49% of participants who were given a whole-plant extract, versus 21% of participants on placebo (

 = .005). The SRS-2 scale median score also improved by 14.9% on plant extract versus 3.6% placebo (

 = .009). Common side effects included somnolence and decreased appetite. The study advised caution that while the CBD/THC solution was well-tolerated, the study had several limitations. The data on efficacy was mixed or insufficient, warranting more research.

A study conducted by the Institute of Psychiatry, Psychology, and Neuroscience at King’s College in London used magnetic resonance spectroscopy to examine the effects of a single oral dose of CBD versus a placebo on the brains of 34 male participants, half of whom were diagnosed with autism.

 It is important to note that the study excluded any comorbid major psychiatric or neurological conditions, including traumatic brain injury, certain genetic disorders linked with autism, low IQ, and those receiving medicines with effects on glutamate-GABA pathways. The study found that while CBD affected the glutamate-GABA systems, the prefrontal-GABA systems responded differently in patients with autism. The authors were clear that the results did not apply to the efficacy of CBD.

There are other clinical trials currently underway that are worth following to see what they discover. Children’s Hospital of Philadelphia recently completed an observational study in collaboration with Zelda Therapeutics, an Australian biopharmaceutical company, to track children with autism who are independently using medical cannabis to address symptoms. Results have not been published yet.

 Another ongoing phase 2, 12-week double-blind, randomized, placebo-controlled trial study, funded by the US Department of Defense, is studying how behavior in children with autism might be affected by 

, a nonpsychoactive phytocannabinoid, which is a safer alternative to CBD.

The University of San Diego is conducting a phase 3 clinical trial in partnership with the Wholistic Research and Education Foundation through the Center for Medicinal Cannabis Research. It seeks to explore 

 on behavioral symptoms in children with autism.

 The University of Colorado, Denver, is currently also recruiting participants for a randomized placebo-controlled study with a predetermined crossover design to assess 

 on common behavioral problems related to autism.

 All participants will receive CBD for at least 12 weeks. Some will receive CBD for the entire 27 weeks of treatment.

New York University’s Langone Health research facility is in the recruiting stage for a 6-week open trial to study CBD use in participants aged 7 to 17 with autism. It will assess dosing, symptoms changes, side effects, and primary and secondary outcomes to 

While interest grows in cannabis, the medical community is eager for more research on how it might affect autism. In the United States, tight controls and a lack of adequate funding limits how cannabis is studied.

The National Institute on Drug Abuse (NIDA) contracts with the University of Mississippi, the only facility in the country registered with the Drug Enforcement Agency (DEA) to grow and supply the cannabis that scientists are allowed to study. However, these strains are often not the ones widely distributed to the public in states that have legalized medical cannabis.

Different strains of cannabis have diverse chemical variations, according to Donald Abrams, MD, an integrative oncologist at Zuckerberg San Francisco General Hospital and Trauma Center.

 Products with higher amounts of THC, for example, are often used to treat cancer-related nausea and poor appetite, while CBD tends to be used for chronic pain, inflammation, and insomnia. Abrams also pointed out that NIDA’s supply included mostly low-THC, zero-CBD strains, which can challenge researchers struggling to move with the times and study emerging products on the market. NIDA’s focus on substance abuse also means it is more focused on the negatives of cannabis, rather than any potential benefit.

Even NIDA has acknowledged federal limitations on cannabis research. In 2015, 

, MD, NIDA’s director, spoke before the US Senate Caucus on International Narcotics Control.

 She acknowledged application barriers to research and the lack of well-controlled clinical trials. She also noted CBD’s potentially positive effect on a variety of symptoms, including children with drug-resistant epilepsy.

Approval to conduct cannabis research comes from both the FDA and the DEA. The process takes more than a year, with some researchers waiting even longer. Strict protocols govern how cannabis is stored, requiring limited access in an alarm-controlled, locked container physically attached to a floor or wall, according to the 

 These obstacles create a catch-22 for medical marijuana research, according to the State of Cannabis Research Legislation in 2020, a report led by Ali Zarrabi, MD, associate director of outpatient support and palliative care at Emory University.

“Investigators cannot conduct research on cannabis until they demonstrate that it has a medical use, and they cannot show that it has a medical use until they conduct research,” the report states.

The American Academy of Child and Adolescent Psychiatry discourages the use of marijuana and cannabinoids in children with autism, a stance that has not changed despite the FDA’s approval to use cannabidiol to treat seizures. The American Academy of Pediatrics holds a similar stance, although it acknowledges it may provide an option for children with life-limiting or severely debilitating conditions when current therapies are inadequate.

Despite these cautions, individuals with any number of ailments are flocking to cannabis for treatment. But there is a huge gap between the desire for treatment and the research needed for doctors to give approval. Additionally, it is rare for any cannabis curriculum to be included in residencies and fellowships, but this is changing.

We are taught to practice evidence-based medicine as psychiatrists, placing the highest importance on meta-analysis and well-designed double-blinded RCT in research. Most psychiatrists try to adhere to the established standards of evidence-based medicine. However, there are times when we prescribe medications for off-label purposes based on clinical experience, often with reasonable or good results. Could CBD be used in the same way, especially in cases where we are hitting a dead end with existing treatment strategies?

There is some anecdotal evidence that cannabis can positively affect autism. But there is a lack of well-designed clinical trials with adequate sample sizes to study its efficacy and assess for safety. We need to study pure CBD separate from pure THC, without the confounding unknown effects of other molecules present. At this time, however, clinical trials of THC in individuals under the age of 20 are probably unwise.

As of today, we lack evidence-based recommendations to support CBD and cannabis use in children with autism. We lack guidelines on overall safety and efficacy, as well as factors like dosage, the required ratio of CBD to THC, symptoms that will likely respond, and the duration of treatment. We also lack guidance on how to discuss this sensitive topic with our patients, who may be asking for advice and are ready to pursue it on their own. See 

 for some tips on how to advise patients.

Cannabis is prescribed as a treatment for autism in 14 states. Is it the wonder drug patients and families have been waiting for? 

Medical Marijuana for Autism 

In the 1930s and 1940s, researchers identified childhood autism as a unique condition. At the same time, many believed that children became autistic because they had cold, intellectual, emotionally withholding mothers.

But Clara Park, a woman whose daughter had autism, set out to understand autism differently and, along with other families and dedicated researchers, she upended the medical establishment’s view of her daughter’s condition.

In this Mental Health Minute, Marga Vicedo, PhD, discusses her recent book, 

Intelligent Love: The Story of Clara Park, Her Autistic Daughter, and the Myth of the Refrigerator Mother

. Along with telling Park’s story, the book shows how medical research can both reflect social attitudes and change them.

is professor of the history of science and medicine in the Institute for the History of Philosophy of Science and Technology at the University of Toronto. She is the author of 

Has the history of psychiatry informed your practice? 

Share comments with your colleagues by emailing 

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

A mother’s quest to understand her child revolutionized our understanding of autism. 

What Causes Autism?

 (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.

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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.

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

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