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Treating Patients With Co-occurring Autism Spectrum Disorder and Substance Use Disorder: A Clinical Explorative Study


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Background Substance use disorders (SUDs) have been assumed to be rare in individuals with autism spectrum disorder (ASD). Recent research suggests that the rates of SUD among individuals with ASD may be higher than assumed although reliable data on the prevalence of SUD in ASD are lacking. Typical interventions for SUD may be particularly unsuitable for people with ASD but research on intervention and therapy are limited. Methods This study addresses ways of improving services for individuals with ASD and SUD by enhancing the competence of professionals in ordinary SUD outpatient clinics. Three therapists were given monthly ASD education and group supervision. The participants were ordinary referred patients who wanted to master their problems with alcohol or drugs. Four patients, all men diagnosed with ASD and intelligence quotient (IQ) ⩾ 70 completed the treatment. The participants were given cognitive behavioural therapy (CBT) modified for their ASD over a minimum of 10 sessions. The therapies lasted between 8 and 15 months. Standardised assessments were conducted pre- and post-treatment. Results Post-treatment, 2 participants had ended their drug and alcohol abuse completely, 1 had reduced his abuse, and 1 still had a heavy abuse of alcohol. Physical well-being was the most prevalent reported positive aspect of drug or alcohol use, whereas the experience of being left out from social interaction was the most frequent negative aspects of intoxication. Conclusions CBT may represent a promising treatment option for individuals with ASD and SUD. The results suggest that patients’ symptoms can be reduced by providing monthly ASD education and group supervision to therapists in ordinary SUD outpatient clinics. This group of patients need more sessions than other client groups, the therapy has to be adapted to ASD, ie, direct, individualised, and more extensive. Moreover, the patients need psychoeducation on ASD generally, social training, and support to organise several aspects of their lives and some patients need more support than can be provided in an outpatient clinic.
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Substance Abuse: Research and Treatment
Volume 13: 1–10
© The Author(s) 2019
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DOI: 10.1177/1178221819843291
According to the United Nations Office on Drugs and Crime,1
approximately 29.5 million people, or 0.6% of the global adult
population, have a substance use disorder (SUD). There are a
number of mental health conditions that are particularly associ-
ated with high rates of SUD, including personality disorders
(25%-51%), affective disorders (16%-35%), anxiety (16%-18%),
schizophrenia (47%), bipolar disorder (56%), and post-trau-
matic stress disorder (PTSD; 37%).2–5 Certain developmental
disorders, notably attention deficit hyperactivity disorder
(ADHD), are also overrepresented in treatment-seeking SUD
populations.6–8 For example, a recent meta-analysis showed a
23% comorbidity of ADHD in an adult mixed SUD popula-
tion, ranging from 10% to 54% in different studies.7 In contrast,
among individuals with autism spectrum disorder (ASD), SUD
has generally been assumed to be relatively uncommon.9–11
ASD is a neurodevelopmental disorder characterised by deficits
in social interaction and communication together with a
restricted repertoire of activities and interests.12,13 Because of
their social and communication deficits, many adolescents and
adults with ASD have very limited social networks outside their
family14,15 and it has been suggested that this may be a protec-
tive factor for SUD10 and that young people with ASD are less
likely to be influenced by their peers when it comes to experi-
menting with alcohol or drugs.9
Nevertheless, recent research suggests that the rates of SUD
among individuals with ASD may be higher than is often
assumed.16 A recent systematic review of the literature17 identi-
fied 18 studies that examined the association between ASD
and SUD. A total of 11 papers specifically explored the fre-
quency of SUD in ASD but reported that the rates ranged
Treating Patients With Co-occurring Autism
Spectrum Disorder and Substance Use
Disorder: A Clinical Explorative Study
Sissel Berge Helverschou1, Anette Ræder Brunvold2
and Espen Ajo Arnevik3
1NevSom – Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias,
Department of Rare Disorders, Oslo University Hospital, Oslo, Norway. 2SUD Outpatient Clinic,
Department of Addiction Treatment, Oslo University Hospital, Oslo, Norway. 3Section for
Addiction Research, Department of Addiction Treatment, Oslo University Hospital, Oslo, Norway.
BACKGROU ND: Substance use disorders (SUDs) have been assumed to be rare in individuals with autism spectrum disorder (ASD).
Recent research suggests that the rates of SUD among individuals with ASD may be higher than assumed although reliable data on the
prevalence of SUD in ASD are lacking. Typical interventions for SUD may be particularly unsuitable for people with ASD but research on
intervention and therapy are limited.
METHODS: This study addresses ways of improving services for individuals with ASD and SUD by enhancing the competence of profes-
sionals in ordinary SUD outpatient clinics. Three therapists were given monthly ASD education and group supervision. The participants were
ordinary referred patients who wanted to master their problems with alcohol or drugs. Four patients, all men diagnosed with ASD and intel-
ligence quotient (IQ) 70 completed the treatment. The participants were given cognitive behavioural therapy (CBT) modified for their ASD
over a minimum of 10 sessions. The therapies lasted between 8 and 15 months. Standardised assessments were conducted pre- and
RE S U LTS: Post-treatment, 2 participants had ended their drug and alcohol abuse completely, 1 had reduced his abuse, and 1 still had a
heavy abuse of alcohol. Physical well-being was the most prevalent reported positive aspect of drug or alcohol use, whereas the experience
of being left out from social interaction was the most frequent negative aspects of intoxication.
CONCLUSIONS: CBT may represent a promising treatment option for individuals with ASD and SUD. The results suggest that patients’
symptoms can be reduced by providing monthly ASD education and group supervision to therapists in ordinary SUD outpatient clinics. This
group of patients need more sessions than other client groups, the therapy has to be adapted to ASD, ie, direct, individualised, and more
extensive. Moreover, the patients need psychoeducation on ASD generally, social training, and support to organise several aspects of their
lives and some patients need more support than can be provided in an outpatient clinic.
KEYWORDS: autism spectrum disorders, substance abuse disorder, treatment
RECEIVED: March 8, 2019. ACCEPTED: March 15, 2019.
TYPE: Original Research
FUNDING: The author (s) received n o nanci al supp ort for th e resear ch, auth orship, a nd/or
publication of this article.
DECLARATION OF CONFLICTING INTERESTS: The author(s) declared no potential
conic ts of interest with r espec t to the rese arch, aut horship, and/or p ublica tion of th is arti cle.
CORRESPONDING AUTHOR: Sissel Ber ge Helver schou , NevSom – N orweg ian Centr e of
Expertise for Neurodevelopmental Disorders and Hypersomnias, Department of Rare
Disord ers, Os lo Univer sity Ho spita l, P.O. Box 4956, Nydale n, 0424 Osl o, Norway. Ema il:;
843291SAT0010.1177/1178221819843291Substance Abuse: Research and TreatmentHelverschou et al
2 Substance Abuse: Research and Treatment
widely, f rom 0.7% to 36%, and most studies involved highly
selected samples, such as offenders or patients in mental hospi-
tals. Sample sizes were variable and age, intellectual level, and
sex distribution of participants varied between samples. Few
studies reported formal diagnostic criteria for SUD, and defini-
tions of SUD ranged from ‘having experienced trouble with
alcohol or drugs’ to ‘current substance addiction’. Such incon-
sistencies limit comparisons between studies, but although
there are difficulties in establishing an overall estimate for the
co-occurrence of ASD and SUD, most existing research sug-
gests that the rates are lower than those in the general popula-
tion. In contrast, a recent Swedish study, based on register data,
found that there was a much higher risk of SUD among indi-
viduals with ASD than among non-ASD controls (odds ratio
[OR] = 2.6; 95% confidence inter val = 2.4-2.9).18 The risk was
particularly high in individuals with ASD and comorbid
ADHD (OR = 8.3; 95% confidence interval = 7.4-9.2), but
there was no increased risk for individuals with ASD and intel-
lectual disability (ID) (OR = 1.1; 95% confidence interval = 0.9-
1.3). Other studies suggest that SUD is more likely to occur in
individuals with ASD who are more socially outgoing, or of
higher intelligence than those who are more socially withdrawn
or of lower ability.17,19 Only 1 study has compared the preva-
lence of SUD among individuals with ADHD or ASD. In this
sample, comorbidity was almost twice as high in ADHD (58%)
as in ASD (30%).19
The high frequency of anxiety and other psychiatric disor-
ders among individuals with ASD has been proposed as a prin-
cipal reason for their use of alcohol or illegal drugs.20,21 Other
reasons for drug or alcohol use, reported by individuals with
ASD, include a reduction in social inhibition, the ability to for-
get problems and/or to attain peace of mind, to get through the
day, or to overcome frustration. Kronenberg etal22 emphasise,
however, that although substance use was reported to solve
ASD-related problems in the short term, in the longer term
substance abuse increased already-impaired functioning.
Substance abuse may represent a particular vulnerability factor
for individuals with ASD, as intoxication may further decrease
the ability to anticipate the consequences of their behaviour
and make it even more difficult to behave according to formal
and informal laws.23
The lack of reliable data on the prevalence of SUD in ASD
is paralleled by a lack of intervention research. In the above-
mentioned review,17 no studies of specific treatment strategies
were found; moreover, typical interventions for SUD, for
example, group therapy, may be particularly unsuitable for peo-
ple with ASD. In general, about 50% of individuals seeking
treatment for SUD drop out before completing treatment,24
and to reduce drop-out and enhance therapeutic effects, there
is a need to develop individualised treatment for those patient
groups who do not benefit from regular SUD treatment pro-
grammes. The special characteristics of individuals with ASD
suggest that this may be a subgroup particularly in need of
adjusted SUD treatment.
Kronenberg etal20,22,25 have provided valuable information
for better understanding the needs of patients with co-occur-
ring ASD and SUD, but they did not test specific interventions.
The authors note that the needs of patients with ASD and
SUD are more extensive and more severe than those of indi-
viduals with SUD and ADHD or other psychiatric diagnoses,
and that SUD treatment requires medical, psychological, and
social interventions, as well as support for housing, education,
transportation, and legal services. Furthermore, they argue that
intervention approaches should be instructive and directive.
Cognitive behavioural therapy (CBT) does seem to have
promise in treating other comorbid disorders in ASD, for
example, anxiety.26–29 There is, however, a general consensus
that CBT has to be adjusted to the communication and com-
prehension difficulties and specific needs that characterise
individuals with ASD. There is a particular need to deal with
the social problems more generally. To minimise stress and
anxiety, a rehabilitation plan should include strategies similar
to those typically recommended for people with ASD, such as
the incorporation of familiar routines and activities, and staff-
client interaction should uphold structure and predictability.30
To provide adequate services to individuals with ASD and
SUD, there is a need to develop guidelines and recommenda-
tions for treatment. This study is, to our knowledge, the first
publication reporting experiences from treating this group in a
systematic way. Based on recommendations from previous
ASD and SUD reports20,22,25 together with studies on treat-
ment of psychiatric disorders in ASD,27–29 CBT was chosen as
the main intervention strategy and therapy was provided indi-
vidually in an outpatient clinic to a small group of referred
patients with ASD and SUD.
This study addresses ways of improving services for indi-
viduals with ASD and SUD by enhancing the competence of
professionals in ordinary SUD outpatient clinics. The outcome
of individually focused CBT for individuals with SUD and
ASD is also explored. The aims were to explore the individuals’
explanations for drug and alcohol abuse, to educate and sup-
port therapists in conducting CBT with these individuals, to
explore necessary adjustments to therapeutic techniques, and
to monitor outcome by standardised assessment instruments
and by patients’ own evaluation.
A total of 3 therapists in an ordinary SUD outpatient clinic
were recruited to the project. The therapists were 2 psychiatric
nurses and 1 psychologist and all the three had extensive clini-
cal experience with SUD patients and had training in CBT.
They were given monthly group education and supervision by
a psychologist with long experience in the field of autism. The
main themes of supervision were the characteristics of ASD
and discussions on how to conduct therapy and adjust CBT to
the needs of individuals with ASD.
Helverschou et al 3
All patients were referred by their family doctor to the clinic
because they wanted to overcome their problems with alcohol
or drugs. To enhance the number of patients with ASD, the
project was advertised through websites and flyers at SUD out-
patient clinics, ASD services, and user organisations. The
inclusion criteria were as follows:
Previous diagnosis of ASD according to International
Statistical Classification of Diseases and Related Health
Problems, 10th Revision (ICD-10; WHO, 1992)
Intellectual ability within the normal range, ie, intelli-
gence quotient (IQ) 70;
Aged over 16 years;
Able to attend weekly outpatient sessions.
In total, 7 patients (6 men and 1 woman) were recruited to
the study, but 3 individuals ended treatment before it was fin-
ished and before assessments were completed. The reasons for
drop-out were as follows: sudden death just when treatment
started, 1 therapist ended her participation in the study, and 1
patient was misdiagnosed with ASD. Thus, the final sample
consisted of 4 patients, all men, aged between 22 and 44 years
(mean: 31.4 years). All four were previously diagnosed with
Asperger syndrome by specialists in mental health services. In
addition, they all scored above cut-off on the autism spectrum
quotient (AQ)31 (mean: 31.8; range: 23-42) and all had an IQ
within the normal range (mean: 110.8; range: 102-125). The 4
participants were also diagnosed with anxiety and depression as
co-occurring psychiatric disorders. One individual was in regu-
lar employment, one had been offered a place on a work prepa-
ration scheme, and two were without any regular daily activity.
Two participants had their own apartments, one lived with his
parents and siblings, and one lived in a sheltered home. Pre-
treatment drug use included amphetamines, cocaine, alcohol,
and benzodiazepines; three participants had used a wide mix of
substances; one was dependent on alcohol.
Details on the drug and alcohol use pre- and post-treatment
for the 4 patients who completed the treatment are presented
in Table 1. Based on ICD-10,12 Patient 1 was diagnosed with
F15.2 Other stimulant dependence and F13.2 Sedative, hyp-
notic, or anxiolytic dependence. He used drugs on a daily basis.
Patient 2 was diagnosed with F10.2 Alcohol dependence. He
had used alcohol for 10 years when the project began and drank
12 to 16 bottles of beer (0.5l) 3 to 4 days a week. Patient 3 was
diagnosed with F11.22 Opioid dependence and F13.21
Sedative, hypnotic, or anxiolytic dependence in remission.
Patient 4 was diagnosed with F12.2 Cannabis dependence. He
started with drugs 10 years ago and used drugs on a daily basis.
Mean age of onset was 19.5 years (Patient 1: 27 years, Patient 2:
19 years, Patient 3: 16 years, Patient 4: 16 years old). Mean
duration of drinking/using drugs was 14.3 years (Patient 1:
9 years, Patient 2: 11 years, Patient 3: 28 years, Patient 4: 9 years.)
Pre- and post-treatment assessment
The following assessments were performed before treatment.
IQ was assessed by the WAIS-III32 or the WAIS (Wechsler
Abbreviated Scale of Intelligence).33 The latter covers the age
range from 6 to 89 years and has been found to correlate well
with WAIS-III.34 The AQ30 is a frequently used instrument for
assessing autism symptoms among individuals with intellectual
functioning within the normal range. The AQ has been found
to have excellent test-retest reliability (scores from the first and
second AQs did not differ statistically, t(16) = 0.3, P = .75, and
were strongly correlated). Reasonable face validity and construct
validity have also been demonstrated. The internal consistency
of items in each subscale has been found to be moderate to high
(0.65, 0.77, 0.65, 0.63, 0.67). The Hopkins Symptom
Checklist-25 (HSCL-25)35 was used to assess psychiatric
comorbidity because this instrument is part of routine practice
at the SUD outpatient clinic involved. HSCL-25 includes 25
questions and assesses anxiety, depression, and somatisation
which are the psychiatric disorders most likely to co-occur with
ASD. HSCL is a well-known and widely used screening instru-
ment and it has been demonstrated in several populations that
the total score is highly correlated with severe emotional distress
Table 1. Patients’ alcohol and drug use pre- and post-treatment.
(OUT OF 68)
(OUT OF 68)
OF 68)
(OUT OF 68)
(OUT OF 10)
1 (DUDIT-E) 46 16 526 34 7
2 (Alcohol-E) 19 28 419 32 4
3 (DUDIT-E) 41 13 524 15 8
4 (DUDIT-E) 30 22 4 *
Alcohol-E, Alcohol Use Disorders Identication Test – Extended; DUDIT-E, Drug Use Disorder Identication Test – Extended.
Alcohol-E is reported for the patient with alcohol dependency.
DUDIT-E is reported for the patients with drug use.
Signicance level cannot be computed because there are less than 5 records.
*Missing data – Patient 4 totally ended his drug use, but DUDIT-E was not completed.
4 Substance Abuse: Research and Treatment
of unspecified diagnosis, and the depression score is correlated
with major depression as defined by the Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV).36 Drug Use
Disorder Identification Test – Extended (DUDIT-E)37 and
Alcohol Use Disorders Identification Test – Extended
(Alcohol-E)38,39 were used to assess drug and alcohol use before
and after treatment and positive and negative experiences with
intoxication. These screening tools have moderate to high accu-
racy for identification of dependency diagnoses. The Alcohol
Use Disorders Identification Test (AUDIT) has demonstrated
association with alcohol problem severity, whereas the DUDIT
has demonstrated association with drug and legal problem
severity. The DUDIT has satisfactory measures of reliability
and validity for use as a clinical or research tool. Internal con-
sistency reliability estimates (Cronbach α) are generally >0.90.
Most studies also revealed favourable sensitivity (ranging from
0.85 to 1.00) and specificity (ranging from 0.75 to 0.92) in a
variety of populations.40
The Global Assessment of Functioning (GAF)41 is part of
routine practice at the SUD outpatient clinic and was used to
assess psychosocial functioning before and after treatment. The
GAF is well known internationally and widely used for scoring
the severity of illness in psychiatry. In Norway, the GAF is
mandatory in all mental health services despite reported prob-
lems with both reliability and validity. Overall reliability can be
good, but concurrent validity and predictive validity have been
found to be more problematic and few empirical results for
GAF sensitivity have been reported.42 We used the version in
which symptoms (GAF-S) and functioning (GAF-F) are rated
separately. The Motivational Interview (MI)43 is also part of
routine practice at the clinic and was used to identify the
patients’ goals for and anticipations of therapy and to develop
an individualised plan in collaboration with the patients. Post-
treatment, the Patient Satisfaction Questionnaire (PSQ-18)44
was used to assess patients’ own evaluation of the treatment. All
subscales in PSQ-18 have demonstrated acceptable internal
consistency reliability, and the short form is substantially cor-
related with the long form of the questionnaire as well as with
multiple scales assessing satisfaction with treatment.
To obtain information on the therapeutic experience of
treating patients with ASD and SUD and the challenges of
adapting CBT to patients with ASD, the therapists were inter-
viewed individually post-treatment about what they experi-
enced as challenging, what the differences were between
patients with ASD and SUD compared with patients with
SUD only, and about their suggestions and recommendations
for other clinicians who may be treating SUD in individuals
with ASD.
The primary treatment components in CBT include psychoe-
ducation, cognitive restructuring, relaxation strategies, exposure,
and response prevention. The treatment aims at changing ways
of thinking and teaching new strategies for self-monitoring and
coping. The participants were offered CBT over a minimum of
10 sessions. The CBT treatment was modified to meet the
communication and comprehension difficulties that character-
ise autism, and substantially expanded to address ASD-related
clinical characteristics such as social functioning, adaption and
self-care, and circumscribed interests and stereotypies according
to recommendations by Wood etal.45 The therapy was provided
as part of regular clinical practice. The length of each session
varied. Because this was an explorative study, specific manuals
were not used, but the therapists selected materials and exercises
from different available CBT manuals and adjusted these to
individuals’ needs and difficulties.
The study initially aimed to explore the outcome of treat-
ment by CBT over 10 to 20 sessions. However, the time to
establish contact and to assess and complete the different ele-
ments of the treatment was more time-consuming than antici-
pated. Most participants had additional problems that had to
be dealt with, such as organising their daily life and living con-
ditions and problems in completing education or getting a job.
Thus, it was not considered ethical to end treatment after 20
sessions and up to 40 sessions were found to be necessary.
Ethical issues
Informed consent was obtained from all the patients. Data
were anonymised and processed without name, identification
number, or other directly recognisable types of information.
The project was approved by the Privacy Protection Supervisor
(local institutional review board [IRB]) at Oslo University
Hospital, Oslo, Norway. Approval #2013/17582. To preserve
anonymity, the results are presented mainly on a group level.
Four participants completed the treatment. They were pro-
vided with 30 to 40 sessions each, and in addition there were
failed appointments, collaboration meetings with local profes-
sionals, care staff, and family member, and phone calls. Therapy
lasted between 8 and 25 months (mean = 17 months). Post-
treatment, 2 participants had ended their drug and alcohol
abuse completely, 1 had reduced his abuse, and 1 remained
heavily dependent on alcohol. More details on the patients’
alcohol and drug use are presented in Table 1. Most patients
changed positively their thoughts about drugs and alcohol
from pre- to post-treatment, but unfortunately data were miss-
ing from one of the completers, and significance level could not
be computed because there were fewer than 5 records.
Among the positive and negative aspects of drug and alco-
hol use reported pre-treatment, physical well-being was
described as the most positive aspect by 3 participants. One
participant reported psychological well-being as the most posi-
tive. The experience of being excluded from social interactions
was reported as the most negative aspect of intoxication by 2
participants. One participant reported crime and violence
Helverschou et al 5
involvement as a negative aspect of drug or alcohol use, and one
also reported that drug and alcohol use might reduce physical
health. Examples are listed in Table 2.
Pre- and post-treatment functioning (GAF) are presented
in Figure 1. Participants 1 and 4 showed improvement in both
functioning and symptoms (Person 1 F: T0 = 45 and T1 = 60;
Person 1 S: T0 = 51 and T1 = 65; Person 4 F: T0 = 39 and
T1 = 64, Person 4 S: T0 = 51 and T1 = 64). Participant 3 showed
improvement in functioning (Person 3 F: T0 = 40 and T1 = 61)
but only slight improvement in symptoms (Person 3 S: T0 = 45
and T1 = 50). Participant 2 showed a decline in functioning
accompanied by a slight decline in symptoms (Person 2 F:
T0 = 42 and T1 = 37; P2 S: T0 = 43 and T1 = 41).
The patients’ evaluation of therapy was assessed by PSQ-
1843 which include 8 questions that are rated from 1 to 4
(1 = not satisfied, 4 = very satisfied). Although there is variation,
in general the ratings are high with a mean item score of 3.3
and a mean total score of 26.5 (max rate = 32).
In the post-treatment interview, the therapists noted that
the therapy was more time-consuming because the patients
with ASD required several sessions to complete assessments
and to establish goals for the treatment; all the other elements
of therapy also took longer than usually recommended. In
addition, they described therapy with these individuals as chal-
lenging and quite different from therapy with other SUD
patients. In particular, the patients’ communication style often
made the therapists feel helpless and as if they were losing con-
trol, and this led to their shifting towards a more structured and
directive therapeutic approach. Obtaining support from each
other and the supervisor was considered essential for several
reasons: to learn how to structure sessions most effectively; to
continue therapy without becoming dispirited by apparent lack
of success; to explore ways of presenting psychoeducative ele-
ments and how to adjust strategies to ASD characteristics. All
agreed that knowledge of and experience with ASD is crucial
to help these patients overcome their problems with alcohol
and drugs. Likewise, collaboration with family and local pro-
fessionals should be established early in the therapeutic process
because individuals need help with many other aspects of their
lives, such as housing, getting a job, and establishing social con-
tacts with peers who are not involved in drug or alcohol abuse.
Loneliness was described as a significant problem for these
patients. In addition, establishing contact with local support
services early in the therapy may help avoid patients feeing
rejected or disappointed when the course of therapy is com-
pleted. Clinical recommendations based on interviews with the
therapists are listed in Table 3. Adjustments to traditional CBT
are listed in Appendix 1.
To our knowledge, this study represents the first report on
treating SUD in individuals with ASD in a systematic way. The
findings suggest that SUD treatment for individuals with ASD
can work if therapists are provided with ASD-specific educa-
tion and specialist, monthly group supervision. Individually
tailored treatment based on CBT comprising 30 to 40 sessions
was associated with some improvement in 3 of the 4 partici-
pants who completed the treatment. Two patients ended their
use of drugs and alcohol completely, and three of the four par-
ticipants showed improvement in functioning and symptoms.
However, 3 of the 7 participants initially referred to the study
dropped out, which is comparable with SUD treatment gener-
ally. 23 The patient who did not improve was referred to further
treatment because he needed more support than could be pro-
vided in an outpatient clinic. Thus, to minimise drop-out rates
and ensure a better outcome, a range of services adjusted to the
needs of people with ASD are needed.
The main explanations for their drug use reported by the
participants in this study involved physical and psychological
well-being. As previously suggested,20,22,23 this may be a form
Table 2. Positive and negative aspects of intoxication; explanations given by the participants (N = 4).
I drink to reduce my anxiet y and improve my social
skills and concentration.
I started using drugs to nd peace and reduce pain. Now I have lost both my
family and my job.
Then I am able to socialise with others. I still feel socially excluded.
I drink to get peace and forget problems and conicts. When I have been out on town, I have been arrested by the police.
I feel normal when I am intoxicated. I check all the time in the mirror to nd out if have been injured by my drug use.
I get free from worrying and bad thoughts. I get
through the day.
I drink when I am out together with colleagues from work, but I nd it difcult to
control my drinking and get very drunk and have experienced events that I regret
All my problems were solved when I started with
marihuana – I became myself.
I feel ill physically and it is bad for my body.
I am not able to anticipate a life without marihuana.
I get more social, think clearer, and get peace of mind.
6 Substance Abuse: Research and Treatment
of ‘self-medication and a means of attempting to cope with
social difficulties and dealing with anxiety and depression.
However, as noted by Kronenberg etal,20 such strategies tend
to be unsuccessful in the longer term. Among the negative
aspects of drug use reported by the participants was the exclu-
sion from social interactions, and Butwicka etal18 have also
described increased social isolation as a result of drug use by
people with ASD. In addition, 1 participant reported becoming
involved in crime and violence as a negative aspect of drug use,
and this may be associated with the relatively high prevalence
of SUD in cohorts of offenders with ASD.46,47 Overall, sub-
stance abuse seems to contribute to already-impaired function-
ing and may represent a particular vulnerability factor.
Intoxication may further decrease the ability of individuals
with ASD to anticipate the consequences of their behaviour
and make it even more difficult to act appropriately and accept-
ably in social situations.23
The therapists noted that the therapy was more demanding
than with other SUD patients, which corresponds to the expe-
riences described by Kronenberg et al.20,22,25 Among the
modifications they reported was the need to be more structured
and to use more directive strategies; SUD therapy also had to
be individualised, more extensive, and composed of more ses-
sions than with other patient groups. This is in line with the
general consensus that CBT needs to be specially adapted to
meet the communication and comprehension difficulties and
specific needs of individuals with ASD.26–29,30,45 March48
argues for widening the access to CBT for individuals with dis-
abilities and for moving away from manual-based CBT towards
a more individualised and personalised approach that accounts
for comorbidity and individual needs. Therefore, a specific
manual was not used in this study. Due to the large variability
in the group, treatment plans were individually developed and
different materials and exercises from available CBT manuals
were adjusted to the individuals’ needs and difficulties. There is
reason to assume that a general CBT manual for SUD treat-
ment in individuals with ASD will not be expedient because
individual adaptations will always be necessary. In this study,
the participants also needed psychoeducation about ASD gen-
erally and help organise many other aspects of their lives,
Figure 1. Global Assessment of Functioning (GAF) pre- and post-treatment functioning and symptoms.
N = 4, GAF-F = functioning and GAF-S = symptoms, pre-treatment ratings = T0, post-treatment ratings = T1.
GAF-F: T0 - Min = 39, Max = 45, median = 41, standard deviation = 2.65; T1 - Min = 37, Max = 62, median = 60.5, standard deviation = 12.03. The median difference between
GAF-F T0 and T1 calculated by Wilcoxon signed rank test is 0.144, P < .05.
GAF-S: T0 - Min = 43, Max = 51, Median = 48, standard deviation = 4.12; T1 - Min = 41, Max = 65, median = 57, standard deviation = 11.58. The median difference between
GAF-S T0 and T1 calculated by Wilcoxon signed rank test is 0.144, P < .05.
Helverschou et al 7
including housing, employment, social contacts, and leisure
activities without the use of drugs in addition to CBT.
The therapists also noted the difficulties patients had in
understanding the nature of the therapeutic relationship and
their tendency to view the therapist as their personal friend. At
the same time, the therapists felt an emotional involvement
with their clients and were strongly motivated to help them.
They recommend that therapists should have some previous
experience of working with people with ASD before delivering
SUD therapy to this group; they also highlighted the need for
specific support and supervision during therapy. Thus, to
enhance the access to adjusted SUD treatment for individuals
with ASD, this study indicates that therapists need specific
training and supervision and collaboration with other thera-
pists with similar patients. Development of specialised profes-
sional networks and tertiary services may be the ways of
providing therapists with sufficient support and education.
Although the responses were variable, participants mostly
evaluated the therapy as satisfactory which further suggests
that CBT may represent a promising treatment option for
individuals with ASD and SUD. The frequency of SUD among
individuals with ASD is currently unknown, and although
SUD screening is increasingly an integral part of clinical guide-
lines for many mental health conditions, it is not yet part of
routine clinical psychiatric assessment for individuals with
ASD.49 It is therefore likely that the comorbidity is signifi-
cantly underdiagnosed, particularly among higher functioning
individuals with ASD who are at a greater risk of using alcohol
or illegal substances.16 The participants in this study were all
high functioning and this corresponds with previous sugges-
tions that SUD may be more likely to occur in individuals with
ASD who are more socially outgoing, or of higher intelligence
than those who are more socially withdrawn or of lower
An unusual phenomenon was identified in this study which
may be a particular characteristic to be aware of in individuals
with ASD and SUD. Thus, both participants who ended their
drug use completely did it in their ‘own way’, ie, they stopped
their drug use suddenly and did not follow a recommended
reduction plan. This may be related to ASD characteristics
such as inflexibility and literal comprehension. In addition,
most participants thought that they were drug experts and
reported that they provided advice to others about doses and
combination of drugs. However, as therapists discovered dur-
ing psychoeducation about drugs, such expertise was much
Sample size in this study was very small and the study does not
include a control group, so caution is needed when interpreting
the results. Further limitations were homogeneity of ethnicity,
sex, and intellectual ability; thus, the experiences may not apply
to more heterogeneous groups of clients with ASD and SUD.
Table 3. Clinical recommendations – important factors in therapy for ASD and SUD.
Therapy course and structure
Therapy for this group is more complex than simply following a manual.
The therapy has to be more detailed and thorough; length of sessions and duration of treatment usually need to be increased.
To optimise predictability for the patient, sessions should, as far as possible, be at a xed time each week.
It is important to discuss the likely duration of intervention at the beginning of the therapy.
The therapy has to be structured, direct, and concrete, and supplemented with written guidance.
Written plans, notes, and /or homework assignments are an essential adjunct to therapy.
The use of a motivational interview is useful for making a plan for treatment and outcome.
Psychoeducation about ASD characteristics and how they may impact on each individual is important.
Stabilit y is vital – changing therapist is very challenging for patients.
Ending treatment is difcult because the patient may feel rejected.
Therapist characteristics
Therapists should have previous experience of conducting CBT.
It is preferable for the therapist to have had have previous experience of working with individuals with ASD.
Therapists have to be persevering and patient and recognise that they may feel incompetent in dealing with the challenges of autism. They
may also experience a strong emotional commitment to their patient.
Flexibility and creativity are vital therapeutic techniques.
Patient characteristics
Some patients believe that they are drug experts although they seldom are.
Some patients stop using drugs immediately although this can imply a health risk.
Most patients have a challenging communication style and may take control over the sessions.
Collaboration/external support
Some patients will need more support than can be provided in an outpatient clinic.
Supervision by experienced clinicians is vital, as is collaboration with colleagues.
The therapist should be able to support the patient after ending the therapy – and offer follow-up sessions as needed.
It is crucial to establish collaborations with other relevant services and with the family.
It is important to help the patient establish relationships with local support professional before ending therapy.
Most patients need help with more than SUD; housing, employment, social contacts, etc.
ASD, autism spectrum disorder; CBT, cognitive behavioural therapy; SUD, substance use disorder.
8 Substance Abuse: Research and Treatment
More studies are needed to explore ways of improving access to
SUD treatment for individuals with ASD, as well as optimal
ways of delivering CBT and SUD treatment to this group.
CBT may represent a promising treatment option for individu-
als with ASD and SUD. This explorative study suggests that
patients’ symptoms can be reduced by providing monthly ASD
education and group supervision to therapists in ordinary SUD
outpatient clinics. As reported by other researchers, this group
of patients need more sessions than other client groups and the
therapy has to be direct, individualised, and more extensive.
The patients need psychoeducation on ASD generally, together
with social training and support to organise several aspects of
their lives like housing, employment, social contacts, and lei-
sure activities without the use of drugs. Some patients, too,
need more support than can be provided in an outpatient clinic,
and this highlights the need for a greater range of SUD ser-
vices to meet the needs of individuals with ASD. More research
is indicated in this field, as well as improved professional train-
ing and cooperation between services.
The project represents collaboration between the National
Advisory Unit on SUD treatment, NevSom – Norwegian
Centre of Expertise for Neurodevelopmental disorders and
Hypersomnias, and SUD Outpatient Clinics at Oslo University
Hospital. The essential contribution made by the therapists
and by the patients with ASD and SUD and their families and
caregivers is gratefully acknowledged. We appreciate the sup-
port and contribution from dedicated professionals and user
representatives in the reference group. Thank you to Professor
Emeritus Patricia Howlin at Institute of Psychiatry, London,
UK, for contributing in a final discussion on the manuscript
and help with language.
Author Contributions
SBH and EAA contributed to the conceptualisation and
design of the study. SBH and ARB contributed to the collec-
tion and processing of data. SBH and ARB wrote the first and
final drafts of the manuscript. EAA critically revised the final
manuscript. All authors have made substantial contributions to
the conception and design or acquisition of data and have been
involved in drafting the manuscript or revised it critically. All
authors have approved the final article.
Sissel Berge Helverschou
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10 Substance Abuse: Research and Treatment
Appendix 1 Adjustments to traditional CBT.
The cognitive components have to be adapted to individuals cognitive/language level and language style
The therapy has to be individualised
More structured and greater use of directive strategies
Longer treatment sessions and longer duration of therapy than with other patient groups
Increased time spent on emotional education and stress management
Use of the individuals’ special interests as a starting point
Increased use of visual strategies
The use of drawings or cartoons to aid visualisation of concepts/make them more concrete
Provision of specic social training
Involvement of parents and other caregivers
Psychoeducation about ASD generally is often needed
Help to organise many other aspects of the patients’ lives, including housing, employment, social contacts, and leisure activities without the
use of drugs
... A közelmúltból három tanulmányt emelnék ki, amelyek célzottan vizsgálták a szerhasználat-zavar és az autizmus spektrum zavar egyidejű előfordulását és kezelési, terápiás lehetőségeit Norvégiában és Hollandiában (Helverschou et al., 2019;Kronenberg, 2015;Walhout et al., 2022). Közös a vizsgálatokban a viszonylag kis minta, a homogén csoportösszetétel és a diagnózis időpontjának szórtsága. ...
... Bár mindhárom országban jelen vannak ASD-specifikus képzésben részesült pszichiáterek, a vizsgált terápiák szakmai résztvevői elsősorban gondozók, pszichiátriai nővérek, pszichológusok, ambuláns asszisztensek, szociális munkások és más szakemberek voltak. A szakemberek is a minta specifikus szegmensét alkották: a bekerülés feltétele volt az addiktológiában eltöltött tapasztalat és idő, a speciális feladatkörre felkészítő tréning elvégzése (CBT) és a mentálhigiénés végzettség (Helverschou et al., 2019;Kronenberg, 2015;Walhout et al., 2022). Összehasonlítva, jelenleg Magyarországon két nagy szakmai csoport kvalifikált a feladatra ASD-specifikusan, a felnőttpszichiátria és -addiktológia, illetve az autizmusspecifikus pedagógia. ...
... A tanulmányok eredményei irányadóak lehetnek. A norvég vizsgálat (n=7), bár kis mintával dolgozott, feltárta az egyéni, specifikus terápia jelentőségét a SUD/ASD esetén (Helverschou et al., 2019). Ez a pilotkutatás abba az irányba mutat, hogy a hagyományos rehabilitációs programok, addiktológiai terápiák nem működnek, ahogy az ambuláns pszichiátriai ellátás sem. ...
Az autizmus és a szerhasználat-zavar metszéspontján létezni talán az egyik legnehezebb állapot. Felnőtt, fiatal felnőtt autistaként legtöbbször azt tapasztalják, hogy hibásak, minden mozdulatukkal, megnyilvánulásukkal megsértik az adott társadalmat és annak szabályrendszerét. Azonban a drogokkal, kábítószerekkel, ha csak egy időre is, képesek kontrollálni személyiségük azon részét, amely nem illeszthető be a környezetükbe. Belevághatnak egy olyan életbe, ahol ez lesz az új, speciális érdeklődési körük, ami körül majd az életük forog. Amikor eljön az a pont, hogy a neurotipikus többséghez hasonlóan érzékelik, hogy függők lettek, ugyanaz a szégyen, amit addig is éreztek autista vonásaik, viselkedésük miatt egész életükben, ismét előtérbe kerül, csak intenzívebben. Célom feltárni ezt a speciális helyzetet, amelynek megoldása a jelenlegi ellátórendszerünkben bonyolult és költséges lenne, azonban a megfelelő módszertan és gyakorlatok átvételével a releváns kutatásokban élenjáró országokból, reális célkitűzés lehet a hazai szociális munka számára is. A cikk beérkezett: 2022. 12. 15-én, javítva: 2022. 12. 19-én, elfogadva: 2022. 12. 20-án.
... They showed that adapting CBT to the autistic client's individual needs has been shown to be effective for autistic people, when adapted appropriately. [32][33][34] Future research can identify the extent to which adaptations improve alcohol and drug treatment outcomes for autistic clients. It is interesting to note that the drug and alcohol therapists reported being more confident in their capabilities to do this than CBT therapists (Cooper et al. 29 ), although the samples are very different from each other (e.g., Cooper et al. 29 report their participants had been working for less time, had different levels of qualification, and had little experience of clients with substance misuse as an issue compared with participants in this study). ...
... This is pertinent as the only consistent finding in research to date is the lack of knowledge among professionals on how to treat this group of service users. 1,4,14,34 The perceived issues and challenges to working with autistic clients came under three headings. By far the largest number of issues came under the ''lack of adaptations for autistic clients,'' and this is consistent with the quantitative data mentioned. ...
... Again, this is reflected in the ''Understand autism'' guidance given in the Appendix. This is consistent with Helverschou et al. 34 who found that SUD symptoms can be reduced in autistic adults by providing monthly autism education and group supervision to CBT therapists in general SUD outpatient clinics. The qualitative and quantitative data indicate that therapists are eager to improve their practice for autistic clients through autismspecific training. ...
Background: Autistic people may be at a higher risk of drug and alcohol misuse than the general population. Autistic people, however, are under-represented within drug and alcohol support services. This is the first survey of drug and alcohol therapists' perceptions of current service provision for autistic clients and recommendations for reasonable adjustments that therapists can make to enhance successful outcomes. Methods: We conducted an online survey of 122 drug and alcohol therapists, exploring therapists' demographics, training and experience with autistic clients, approaches and adaptations used with autistic clients, and therapists' confidence with autistic clients. Within two focus groups, 11 members of the autistic and broader autism (e.g., family members, professionals) communities reflected on the reasonable adjustments reported by therapists. Results: Most therapists had autistic clients and most therapists had received no autism-specific training. Alcohol misuse was the most common presenting issue, and most therapists reported that treatment outcomes were less favorable for autistic clients than for other groups. Therapists perceived that barriers to successful outcomes were (1) a lack of autism-specific training, (2) a need to adapt therapy for autistic clients, and (3) a lack of shared perspective between the therapist and the autistic client. Previous research has identified a range of reasonable adaptations and, when asked, therapists were moderately confident in their ability to deliver these. Members of the autistic and broader autism communities coproduced guidance detailing how therapists can best adapt their practice for autistic clients including how to structure sessions and the language to use within sessions. Conclusion: This study highlights a need for practical and theoretical training for drug and alcohol therapists to support successful adaptation to current service provision for autistic clients and to develop a shared perspective on the desired aims and outcomes of the therapeutic process.
... To date, only two studies have examined the utility of evidence-based Cognitive Behavioral Therapy (CBT) in the treatment of adults with SUD and ASD. First, Helverschou et al. [18] in a very small sample of four cases provided CBT-informed supervision to clinicians treating adults with ASD and SUD. Results suggested two participants ended their substance use, one reduced their use, and one continued to heavily drink alcohol. ...
... Conceptualizing these behaviors within an ASD framework can enhance empathy and understanding and provide more tailored SUD treatment where it is greatly needed. In support of this, Helverschou and colleagues have preliminarily shown that providing clinicians who work with clients with ASD and SUD supervision embedded in evidence-based treatments such as CBT even in the absence of a tailored protocol may be effective for SUD [18]. ...
Full-text available
Research highlights the increasing overlap of autism spectrum disorder and substance use disorders in young people. However, no behavioral treatments exist addressing this comorbidity despite great need. A team of clinicians developed an integrated behavioral protocol addressing substance use in youth with autism spectrum disorder. The multidisciplinary team developed 12 youth, 7 parent, and 3 joint modules based on established evidence-based therapies shown to have effectiveness separately addressing autism spectrum and substance use. Two cases are discussed to illuminate this integrated intervention. Adaptations to the protocol were made during feedback from patients and their parents. Further research is needed to determine the effectiveness of this preliminary protocol.
... Two studies that have examined the association between AT and alcohol misuse/abuse in adults have produced conflicting findings [12,19], while a recent study using data from an online survey of 507 predominantly United Kingdom and North American autistic adults found that more than one-half (54%) of alcohol users engaged in past-year HED [20]. Given that other research has linked both alcohol misuse in adults with ASD [21] and BD among adults in the general population [22] to negative outcomes, then examining the AT-BD association will not only increase understanding of the link between autism and alcohol use/ misuse more generally, but it may also have important public health implications. ...
... In conclusion, this study has shown that individuals with AT have increased odds for BD and that this association may be stronger in women and younger and older persons. As there is increasing evidence that substance use/misuse in adults with ASD is associated with a variety of detrimental outcomes [21,47,67,68] the findings of this study highlight the importance of detecting substance misuse in adults with both AT and ASD. In particular, identifying individuals with AT/ASD in substance use services [67] would be facilitated by screening for AT and may be beneficial in efforts to treat substance misuse. ...
Full-text available
Purpose Substance misuse may be elevated in some individuals with autism spectrum disorder (ASD). As yet, however, little is known about the association between autistic traits (AT) and substance use/misuse in adults. This study examined the association between AT and binge drinking (BD) among individuals in Japan. Methods Data were analyzed from 1452 individuals aged 18 and above collected during an online survey in February 2021. Self-reported information was obtained on BD assessed as consuming 5 or more (males) or 4 or more (females) drinks containing any kind of alcohol within a 2-h period. AT were assessed with the Japanese version of the Autism Spectrum Quotient – the AQ-J-10. Logistic regression analysis was used to examine associations. Results The prevalence of past-month BD was significantly higher in individuals with AT compared to those without AT (42.7% > 27.6%). In a fully adjusted analysis that controlled for mental health (anxiety, depression) and attention-deficit/hyperactivity disorder symptoms, individuals with AT had significantly higher odds for BD once a week or more often (OR: 1.54, 95%CI: 1.04–2.29). AT were also associated with significantly higher odds for BD among women (OR: 2.27, 95%CI: 1.08–4.76), and those aged 18–34 (OR: 2.37, 95%CI: 1.09–5.18) and aged 60 and above (OR: 2.15, 95%CI: 1.02–4.53). Conclusion Individuals with AT have higher odds for BD. Increased efforts to detect alcohol use/misuse in adults with AT and AT in adults misusing alcohol may be efficacious in efforts to manage symptoms and eliminate harmful alcohol misuse.
... Historically, autism researchers and service providers assumed that few autistic people developed substance use disorders (SUDs), in part because many autistic individuals have relatively small social networks and there was an assumption that substance use is more common among extroverted individuals or in the context of social gatherings (Helverschou et al., 2019;Ramos et al., 2013). Moreover, autistic individuals with higher support needs who depend substantively on parents or other caregivers for help may have fewer opportunities to engage in substance use and a more difficult time obtaining substances, particularly if under the legal purchasing age. ...
Lay abstract: What is already known about the topic? Hazardous alcohol use is when a person's drinking puts them at increased risk for negative events (e.g. health problems or car crashes). Some studies show that autistic people may be at greater risk for hazardous alcohol use than non-autistic people, while other studies have found that hazardous alcohol use is less common among autistic people than non-autistic people. We need to learn why autistic underage youth choose to drink alcohol or not. The goal of this study was to learn from US autistic youth about their attitudes and behavior related to alcohol. Forty autistic youth aged 16-20 years old were interviewed.What this article adds? Youth described several reasons why they choose to drink alcohol, including feeling like non-autistic people are more accepting when drinking, that it puts them in a less irritable or bored mood, helps them cope with problems, and helps them fit in. Reasons for not drinking alcohol include worries about becoming addicted, medication interactions, not liking the taste, fear of experiencing hangover and other health problems, and concern about acting foolish when drunk.Implications for practice, research, or policy Results reveal that hazardous alcohol use in autistic adults could have its roots in underage experiences that give autistic youth temporary relief from social anxiety, feeling lonely, and challenges with sensory processing. Right now, there are no evidence-based alcohol prevention programs in the United States for autistic people. One or more such programs may be needed. The results from this study could be used to adapt existing programs for non-autistic youth to the unique needs and risk factors of autistic youth.
... 1,4,5 Patients with ASD and co-occurring SUD describe various functions of their substance use: it helps to temporarily forget problems, to clear the mind, to cope with social difficulties, to fill spare time or 'empty days', to deal with frustration/stress and to reduce anxiety and depression. 1,6 What are the consequences of substance use for individuals with ASD? Commonly, SUDs have a negative impact on quality of life as they are responsible for a high rate of accidents, mental health problems, premature death, violence and suicide (attempts). For individuals with ASD, substance use tends to 2 Substance Abuse: Research and Treatment have a profound impact on their functioning, as it dysregulates daily routines. ...
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Background The prevalence of substance use disorders (SUD) in individuals with autism spectrum disorders (ASD) appears to be higher than previously described. Attention has been drawn to developing new treatment approaches for this patient population, as they appear to do less well with traditional addiction treatment. There is very little research addressing treatment outcome. This study aims to introduce and evaluate a manualized group treatment intervention developed specifically for patients with ASD and co-occurring SUD. Methods We developed a group treatment based on cognitive behavioural therapy (CBT) and evaluated outcome measures at the end of treatment and 3-month follow-up. Fifty-seven patients with ASD and co-occurring SUD were included of which 30 completed the group intervention, 27 of them also participated at 3-month follow-up. Results The findings suggest that group treatment can work for patients with ASD and co-occurring SUD. Lower levels of alcohol use ( t = 3.61, P = .002, d = 0.75), craving ( t = 2.65, P = .013, d = 0.51), passive coping styles ( t = 2.32, P = .030, d = 0.48), depression ( t = 3.48, P = .002, d = 0.67), anxiety ( t = 3.02, P = .006, d = 0.58), and stress ( t = 2.62, P = .015, d = 0.51) symptoms were reported after completing the group intervention, with even stronger effects at 3 months follow-up. Conclusions The present study shows promising results of a tailor-made group intervention in a heterogeneous patient population with ASD and co-occurring SUD with positive effects on both symptoms of ASD and SUD.
Background: Autistic people are more likely to report problematic alcohol and other substance use when compared to the general population. Evidence suggests that up to one in three autistic adults may have an alcohol or other substance use disorder (AUD/SUD), although the evidence base for behavioural addictions is less clear. Autistic people may use substances or engage in potentially addictive behaviours as a means of coping with social anxiety, challenging life problems, or camouflaging in social contexts. Despite the prevalence and detrimental effects of AUD, SUD and behavioural addictions in community samples, literature focusing on the intersection between autism and these conditions is scarce, hindering health policy, research, and clinical practice. Methods: We aimed to identify the top 10 priorities to build the evidence for research, policy, and clinical practice at this intersection. A priority-setting partnership was used to address this aim, comprising an international steering committee and stakeholders from various backgrounds, including people with declared lived experience of autism and/or addiction. First, an online survey was used to identify what people considered key questions about Substance use, alcohol use, or behavioural addictions in autistic people (SABA-A). These initial questions were reviewed and amended by stakeholders, and then classified and refined to form the final list of top priorities via an online consensus process. Outcomes: The top ten priorities were identified: three research, three policy, and four practice questions. Future research suggestions are discussed.
Background Recent research has questioned the assumption that people with intellectual disability (ID) or autism spectrum disorder (ASD) are less at risk of substance use disorders (SUDs). Overall, little is known about SUDs among people with intellectual and developmental disabilities (/IDDs). Objective This study aimed to estimate prevalence of SUD among Medicaid enrollees with ASD, ID, or ASD+ID; characterize these groups and types of SUDs; and identify risk of SUD by demographic and clinical characteristics within groups. Methods We used 2008-2012 national Medicaid data to identify enrollees with ASD, ID, ASD+ID and a sample without ASD/ID and identified SUDs within these individuals. We used descriptive statistics to characterize enrollee groups and types of SUDs, calculated SUD prevalence, and used modified Poisson regression to examine adjusted relative risk of SUD within disability groups. Results SUD prevalence increased yearly across disability groups to 1-2.2%, increasing most quickly among those with ASD. Alcohol abuse was the most common SUD among those with ID-only (57%) versus cannabis abuse among the ASD-only group (41%). Risk of SUD was higher among those with co-occurring psychiatric disorders – notably, depression. Conclusions Results highlight increasing prevalence of SUD among Medicaid enrollees with ASD-only and ASD+ID and higher risk of SUD among those with depression and other psychiatric disorders. Understanding access to screening, diagnosis and treatment of SUD among people with I/DDs is a highly important question for future research.
Background and Objectives Recent work highlights an increase in the overlap of autism spectrum disorder (ASD) and substance use disorder (SUD). Little is known about the presence of ASD symptoms in SUD-treatment-seeking populations. Methods The informant-rated Social Responsiveness Scale-2 (SRS-2) was completed at intake to an outpatient SUD clinic for youth aged 16–26 (N = 69). Comparisons were made between those with elevated SRS-2 scores on demographic, psychiatric, and substance use variables. Results Parents of sixty-nine patients with SUD completed the SRS-2. Fourteen (20%) (average age 18.7 ± 2.5) had elevated SRS-2 Total T-scores (≥66) and 55 (average age 18.1 ± 2.8) had non-clinical SRS-2 Total T-scores. There were few differences between groups; however, those with elevated SRS-2 Total T-scores were more likely to have a stimulant use disorder (odds ratio [OR] = 7.59, 95% confidence interval [CI] = 0.77, 101.88; p = 0.05) or an opioid use disorder (OR = 5.02, 95% CI = 0.59, 43.27; p = 0.08) than patients with normal SRS-2 Total T-scores as well as alcohol use in the week prior to intake. Discussion and Conclusions A significant proportion of treatment-seeking SUD outpatients suffer from clinically elevated autistic traits. These findings highlight the importance of assessing for autistic traits in SUD treatment settings yet additional research is needed to determine if these findings are specific to the presence of ASD or secondary to sequelae of specific SUD presentations. Scientific Significance This study is, to our knowledge, the first to have examined the prevalence, morbidity, or clinical characteristics, associated with ASD symptoms in a SUD-specific population.
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Objective: We aimed at determining whether gender modified associations between ADHD and psychiatric comorbidities in adults. Method: We identified adults with ADHD by linking Norwegian national registries and compared them with the remaining adult population (born 1967-1997, ADHD and bipolar during 2004-2015, other psychiatric disorders 2008-2015). Prevalence differences (PDs) and prevalence ratios (PRs) of psychiatric disorders were determined by Poisson regression. Interaction by gender was evaluated on additive (PDs) and multiplicative (PRs) scales. Proportions of psychiatric disorders attributable to ADHD were calculated. Results: We identified 40 103 adults with ADHD (44% women) and 1 661 103 adults (49% women) in the remaining population. PDs associated with ADHD were significantly larger in women than in men for anxiety, depression, bipolar and personality disorders, for example depression in women: 24.4 (95% CI, 23.8-24.9) vs. in men: 13.1 (12.8-13.4). PDs were significantly larger in men for schizophrenia and substance use disorder (SUD), for example SUD in men: 23.0 (22.5-23.5) vs. in women: 13.7 (13.3-14.0). Between 5.6 and 16.5% of psychiatric disorders in the population were attributable to ADHD. Conclusion: The association between ADHD and psychiatric comorbidities differed significantly among men and women. Clinicians treating adults with ADHD should be aware of these frequent and gender-specific comorbidities, such that early treatment can be offered.
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Purpose of review: Until recently, there has been little systematic study of adult life among individuals with autism spectrum disorder (ASD) but recognition of the high psychological and social costs of ASD has led to an increase in adult-focused research over the past decade. The aim of this review is to summarize recent empirical findings on outcomes for adults with ASD. Recent findings: Most research on adult outcomes in ASD indicates very limited social integration, poor job prospects and high rates of mental health problems. However, studies vary widely in their methodology, choice of measures and selection of participants. Thus, estimates of how many adults have significant social and mental health problems are often conflicting. There is little consistent information on the individual, familial or wider social factors that may facilitate more positive social and psychological outcomes. There is a particular dearth of research on older individuals with ASD. Summary: The very variable findings reported in this review reflect the problems of conducting research into lifetime outcomes for individuals with a condition as heterogeneous as ASD. Much more systematic research is needed to delineate different patterns of development in adulthood and to determine the factors influencing these trajectories.
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Despite limited and ambiguous empirical data, substance use-related problems have been assumed to be rare among patients with autism spectrum disorders (ASD). Using Swedish population-based registers we identified 26,986 individuals diagnosed with ASD during 1973–2009, and their 96,557 non-ASD relatives. ASD, without diagnosed comorbidity of attention deficit hyperactivity disorder (ADHD) or intellectual disability, was related to a doubled risk of substance use-related problems. The risk of substance use-related problems was the highest among individuals with ASD and ADHD. Further, risks of substance use-related problems were increased among full siblings of ASD probands, half-siblings and parents. We conclude that ASD is a risk factor for substance use-related problems. The elevated risks among relatives of probands with ASD suggest shared familial (genetic and/or shared environmental) liability. Electronic supplementary material The online version of this article (doi:10.1007/s10803-016-2914-2) contains supplementary material, which is available to authorized users.
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OBJECTIVE Patients with co-occurring autism spectrum disorders (ASD) and substance use disorder (SUD) require special attention from clinical services. Screening for this co-occurrence is not generally an integral part of routine clinical assessments, and failure to identify and understand this group of patients may contribute to a worsening of their symptoms and/or an increase in drug abuse. Thus, there is a need to review the evidence base on patients with co-occurring ASD and SUD in order to enhance clinical practice and future research. METHODS We reviewed all identified papers on patients with co-occurring ASD and SUD. The focus of the review was on epidemiology, patient characteristics, function of drug use, and the effect of current interventions. RESULTS A total of 18 papers were included in the analysis. Eleven papers were based on epidemiological studies, although only one study reported the prevalence of ASD in an SUD population. Two papers explored the role of personality, three papers studied subgroups of individuals serving prison for violent or sexual crimes, and one paper explored the function of drugs in the ASD patient group. There were no studies testing specific treatment interventions. CONCLUSIONS In most of the treatment settings studied, there were relatively few patients with co-occurring ASD and SUD, but due to differences in study samples it was difficult to establish a general prevalence rate. The one consistent finding was the lack of focused treatment studies. There is clearly a need for research on interventions that take account of the special needs of this patient group.
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Patients with a substance use disorder (SUD) and co-occurring attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) often start using substances in an attempt to cope with the stress related to their ADHD or ASD. To improve treatment for these patient groups, it is important to identify and compare the various coping styles between SUD patients with and without ADHD or ASD and with subjects from a general population sample. Cross-sectional study using the Utrecht Coping List (UCL) in 50 SUD patients, 41 SUD + ADHD patients, 31 SUD + ASD patients and 1,200 railway employees. Compared with the reference group, all three SUD groups showed a significant higher mean on the Palliative reaction, Avoidance, and Passive reaction subscales of the UCL. The scores for all UCL subscales of the SUD and the SUD + ADHD groups were very similar. However, the SUD + ASD group scored higher on Passive reaction and lower on Reassuring thoughts than the SUD and the SUD + ADHD groups and lower on Expression of emotions subscale in comparison with the SUD + ADHD group. Regardless of the presence of a co-occurring disorder, SUD patients reported more palliative, avoidant and passive coping when confronted than people in the general population. In addition, SUD patients with co-occurring ASD were different from other SUD patients in their coping and professionals should take this into account when working on more adaptive coping strategies with these patients.
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Low prevalence of substance-use disorder has been reported in adults with autism. However, on a superficial level, adults with high-functioning autism (HFA) display a 'normal' façade when they drink alcohol, which may explain why their alcohol dependency is not better diagnosed. Here, we report two cases of HFA adults who use alcohol and psychostimulants to cope with their anxiety and improve their cognitive abilities and social skills. We analyze how neurocognitive traits associated with HFA may be potential triggers for substance-use disorder. Better identification of autism and its cognitive impairments, which may be vulnerability traits for developing substance-use disorders, could help improve the diagnosis and treatment of substance-use disorders among this population.
There is limited literature available on the comorbidity between autism spectrum disorder (ASD) and substance use disorder (SUD). This paper reviews existing literature and exemplifies the challenges of treating this population with a case report of an adult male with ASD and DSM-5 alcohol use disorder. This review and case study seeks to illustrate risk factors which predispose individuals with ASD to developing SUD and discuss the obstacles to and modifications of evidence-based treatments for SUD. A review of the therapeutic interventions implemented in the treatment of this young male are described to highlight potential recommendations for the general management of SUD in those with ASD.
† The Global Assessment Scale (GAS) is a rating scale for evaluating the overall functioning of a subject during a specified time period on a continuum from psychological or psychiatric sickness to health.In five studies encompassing the range of populations to which measures of overall severity of illness are likely to be applied, the GAS was found to have good reliability. GAS ratings were found to have greater sensitivity to change over time than did other ratings of overall severity or specific symptom dimensions. Former inpatients in the community with a GAS rating below 40 had a higher probability of readmission to the hospital than did patients with higher GAS scores.The relative simplicity, reliability, and validity of the GAS suggests that it would be useful in a wide variety of clinical and research settings.
This study examined the characteristics of adults with autism spectrum disorder who have undergone a forensic examination and explored any relationships between the diagnosis and the offence. The reports described 41 men and 7 women. The autism spectrum disorder was diagnosed late (mean age: 25.3 years), and 22 of the 48 cases were diagnosed with autism spectrum disorder for the first time by the forensic experts. The education level and employment status were low. Family networks were close, but social networks outside the family were limited. Co-morbid diagnoses were common, and more than half of the group knew their victims. The examined individuals constitute a vulnerable and heterogeneous group, as do offenders within other diagnostic categories. Unlike most others who commit criminal acts, the majority of the individuals with autism spectrum disorder in this study showed no evidence of substance abuse, had a close relationship to their victims and were willing to confess to the accused crime. No clear association between the characteristics of autism spectrum disorder and the criminal act were identified, but in most cases, autism spectrum disorder characteristics, such as idiosyncratic comprehensions and obsessions appeared to be related to the motive for the offence. © The Author(s) 2015.