Autism is a behavioral disorder, and like all behavioral disorders, also known as psychiatric or mental health disorders, its description is in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). Autism was first listed as a diagnosis on its own in 1980, before that it was listed as a symptom under a childhood variant of schizophrenia. There are two categories of symptoms that define ASD: category A is made up of deficits in social and communication skills; category B includes rigid, restrictive and/or repetitive behaviors.
Autism is a spectrum. That means it ranges from mild to severe. And that it is sometimes apparent as soon as the child can or should be able to talk, while other times it is not apparent until the child is old enough to be a parent him or herself. It also means that some people require a lot of help through life, while others can be high-functioning and even highly successful while needing little to no assistance along the way. Most people working in pediatric clinics have a sense for when a patient is on the spectrum; it is generally through their behavior and mannerisms during a visit. Pediatric offices regularly screen for autism at wellness visits with toddlers but must survey for it in later years. Naturally, when the suspicion is there on the physician’s side but not on the parents’, it can lead to a difficult conversation. Cautious honesty is the best policy which means the medical professional is likely to say, “I am concerned about this possible diagnosis.”
What are the next steps after a concern for a possible ASD diagnosis has been raised? That depends somewhat on local resources, but it is largely the same throughout North America: referral to audiology to rule out hearing loss as the cause for any associated language delay and referral for an evaluation by a trained professional, such as a psychiatrist, a developmental-behavioral pediatrician, or in some communities, a general pediatrician); genetic testing; and connecting families with support groups and government resources.
When people speak of the science around ASD, what they often mean is pathophysiology: the underlying physical/biological cause (etiology) of the condition? That is still unknown, but some genes have been associated with an increased risk for developing it and there is new research on the presence of environmental factors to ascertain the degree they might contribute. But we know that autism can run in families, so there is ample evidence of a genetic component. Unlike how it happens with diseases of the body, we have not been able identify an abnormal cell or some other simple definitive biological marker.
We know autism is found in males more than females by a ratio of nearly 4 to 1 and has been for decades. The work of the United Kingdom’s leading researcher on ASD, Simon Baron-Cohen, provides a theory of its cause being a hyper-male brain, presupposing that the male brain has a greater interest in things than it does in people relative to its hypothetical counterpart, the female brain. In addition, children whose mothers have polycystic ovarian syndrome (PCOS), a gynecological condition wherein the afflicted woman has higher levels of androgen (testosterone and its precursors), are known to have an increased risk of ASD.
Aside from the challenge of having a young child diagnosed with ASD is the later challenge of having a burgeoning teenager—a son or daughter in the early stages of puberty—on the autism spectrum. We know there are changes associated with rising levels of testosterone in all boys; add to that a difficulty understanding boundaries and unwritten social rules and you have a recipe for some typically unacceptable behaviors. School is also a challenge due to the difficulty many of these children have with transitions, as the school day is one defined by multiple transitions: start- time, various periods, lunch, recess, then unplanned schedule or classroom adjustments, and end-of-school-day dismissal issues.
A further challenge is that very picky eating is a common rigid and restrictive behavior (the B category in the DSM-V description) for patients on the spectrum; this can result in secondary obesity or malnourishment. Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating disorder sometimes seen in these patients. Also, they’re frequently non-verbal, and with their eating habits, they can be prone to constipation and/or dental problems. These secondary conditions can be painful, and oftentimes the only clue that these patients are in pain (since some are non-verbal) is a sudden increase in irritability.
Fortunately, most doctors today treat this as the chronic condition that it is by having patients come in more often than annually for checkups, the hope being that they will catch these common problems early and intervene before they become bigger problems. ASD is a lifelong condition. While many interventions can help lessen the severity of symptoms over time, there is no cure for it. No medication exists for ASD per se; however, it is not uncommon to see some medications used for symptom relief. These patients often have difficulty falling or staying asleep and sometimes use melatonin to help with it. Associated irritability, which is frequently due to the difficulty with transitions, often becomes a significant concern once school begins. It can also make dental visits and immunizations a trying ordeal with injury risks for both patients and caregivers (from kicking, self-harming and other forms of resistance on the patient’s part) that require mild sedation.
In recent years, drugs have been recognized as being very effective at mitigating this irritability and the associated aggression. Unfortunately, those drugs tend to have downsides which further exacerbate the obesity and associated metabolic problems that are already common due to unhealthy eating habits in these patients. Obviously this discussion about medications is an individually prescribed process through one’s physician.
Many patients with ASD see an improvement in their symptoms later in life after using a non-pharmaceutical intervention called Applied Behavior Analysis (ABA). Training in ABA for school personnel and parents is usually readily available. You can ask your doctor or school personnel for further information.
Medical and educational professionals are great resources for parents handling the challenges of ASD in their family. All we know for sure is that one size definitely does not fit all when it comes to the management of autism.
Caring for children and adolescents with ASD can be a challenge, but I feel it’s lessened by viewing each case through the lens of Jewish values. These values provide moral clarity and spiritual confidence in what’s otherwise a very complex clinical situation. Believing that each of us is made in G-d’s likeness, we each have intrinsic dignity; it is important to demonstrate that tenet in each interaction with the family of an autistic child by making sure your office is a welcoming place to the entire family. We know that practicing chesed, or loving-kindness, is of primary importance (in Torah, we are also instructed by G-d to love our neighbor as we love ourselves, which can be done through acts of chesed); sometimes an act of chesed (which is closely related to compassion)—such as opening the office early for a patient who gets anxious around strangers or calling the family after a busy day in the office to check on everyone—sometimes little acts of loving-kindness like those can make all the difference in what was otherwise a difficult day for everyone involved. And sometimes, when considering tikkun olam, think of ways you can make the environment more comfortable for someone on the spectrum. One way might be by giving them more time during the appointment for a more gradual transition (and a less stressful visit). Again, these are small practices that go a long way towards making a family feel welcome and have a sense of belonging.
Our Jewish teachings tell us it is our individual responsibility to take care of each other, to be our brother’s keeper, protect each other, to improve our conditions for each other, and that is what pediatricians and others everywhere are trying to do today for friends and families living with ASD.
May we all follow our teachings and open our hearts to those with autism spectrum
disorder at every opportunity.
Written in September of 2025
By Jacob Sheff, DO
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