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

Abstract

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.

Full text

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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.
ABSTRACT
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
post-treatment.
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:
shelver@ous-hf.no; s.b.helverschou@live.no
843291SAT0010.1177/1178221819843291Substance Abuse: Research and TreatmentHelverschou et al
research-article2019

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.
Method
Participants
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.
PATIENT PRE-TREATMENT POST-TREATMENT
POSITIVE ABOUT
USING DRUG
(OUT OF 68)
NEGATIVE ABOUT
USING DRUGS
(OUT OF 68)
THOUGHTS
ABOUT DRUG
USE (OUT OF 10)
POSITIVE ABOUT
USING DRUG (OUT
OF 68)
NEGATIVE ABOUT
USING DRUGS
(OUT OF 68)
THOUGHTS
ABOUT DRUG USE
(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.
Intervention
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.
Results
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.
Discussion
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).
WHY DO YOU USE DRUGS OR ALCOHOL? WHY DO YOU WANT TO STOP USING DRUGS OR ALCOHOL?
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
afterword.
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
ability.16,18
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
exaggerated.
Limitation
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.
Conclusions
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.
Acknowledgements
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.
ORCID iD
Sissel Berge Helverschou https://orcid.org/0000-0003-37
10-6733
REFERENCES
1. United Nat ions Office on Drug s and Crime. World D rug Report 2 017 (Report No.
20). Vienna, Austr ia: United Nations P ublication; 2017.
2. Stinson FS, Grant BF, Dawson DA, Ruan W J, Hua ng B, Sa ha T. Comorbidit y
between DSM-IV a lcohol and speci fic dr ug use disorder s in the United States:
result s from the Nationa l epidemiologi c survey on a lcohol and related c onditions.
Drug Alcohol Depend. 2005;80:105–116.
3. Grant BF, Stinson F S, Daw son DA, et al. Prevalence and co-occur rence of sub-
stance use disorders and independent mood a nd anxiet y disorders: results from
the National Epidemiologic Survey on Alcohol and Related Conditions. Arch
Gen Psych. 200 4;61:807–816.
4. Regier DA, Farmer ME , Rae DS, et al. Comorbidity of mental disorders with
alcohol and other d rug abuse. Results f rom the Epidemiologic Catchment Area
(ECA) study. JAMA. 19 90 ;2 64 :2 511–2518.
5. Gielen N, Havermans RC, Tekelenburg M, Jansen A. Prevalence of post-trau-
matic st ress disorder a mong patients w ith substance u se disorder: it is h igher than
clin icians think it is. Eur J Psychot raumatol. 2012;3:PMC3415609.
6. van de Glind G, Konstenius M, Koeter MW J, et al. Variability in the pre valence
of adult A DHD in treatment seeking substance use disorder patients: results
from an internat ional mu lti-centre study exploring DSM-IV and DSM-5 crite-
ria. Drug Alcoh ol Depend. 2014;134:158–166.
7. van Emmerik-van Oort merssen K, van de Glind G, van den Brink W, et al.
Preva lence of at tention-deficit hy peractiv ity disorder in substa nce use d isorder
patients: a meta-analysis and meta-regression ana lysis. Drug Alcohol Depend.
2012;122:11–19.
8. Solberg BS, Halmøy A , Engeland A, Igland J, Haavi k J, Klu ngsø yr K. Gender
differences in psychiatric comorbidity: a population-based study of 40 0 00 adu lts
with at tention deficit hyperac tivity disorder. Acta Psych Scan d. 2017;137:176 –186.
9. Ra mos M, Boada L, Moreno C, Ljlorente C, Romo J, Parel lada M. Attit ude and
risk of substance use in adolescents diagnosed w ith Asperger s yndrome. Dr ug
Alcohol Depend. 2013;133:535–54 0.
10. Sa ntosh PJ, M ijovic A . Does pervasive developmental disorder protect ch ildren
and adolescents against drug and alcohol use? Europ J Child and Adoles Psych.
2006;15:183–188.
11. Woodbur y-Smit h MR, Clare ICH, Holland AJ, Kea rns A. High functioning
autistic spectrum disorders, offending and other law-breaking : findi ngs from a
community sample. J Forensic Psych Psychol. 20 06;17:108 –12 0.
12. World Health Organiz ation.  e ICD-10 Classificati on of Mental and Behavioural
Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Sw itzerland:
World Health O rgan ization; 1992.
13. American Psychiatric Associat ion. Diagnostic and Statistical Manual of Mental
Health Disorders, 5th ed. Washington, DC: American Psyc hiatric Associat ion;
2013.
14. Brugha TS, Mc Manus S, Bankar t J, et al. e epidemiology of autism sp ectr um
disorders in adu lts in the community in England . Archiv Ge n Psych. 2011;68:
459– 466.
15. Howlin P, Magiati I. Autism spectrum disorder: outcome in adulthood. Neuro-
develop Disord. 2017;30:69–76.
16. Reng it AC, McKowen JW, O’Brien J, Howe YJ, Mc Dougle CJ. Brief report:
autism spectr um disorder and substa nce use d isorder: a review and case study. J
Autism De v Disord. 2016;4 6:2514 –2519.
17. A rnev ik EA , Helver schou SB. Autism spectrum disorder and co-occurring sub-
stance use disorder – a systematic revie w. Subst Abuse. 2016;10: 69–75.
18. Butwicka A, Långström N, L arsson H, et al. Increased risk for substance use-
related problems in autism spectr um disorders: a population-based study. J
Autism De velop Disord. 2 017;47:80 –89.
19. Sinzoo B, van den Brinck W, Koeter M, Gorissen van E enige M , van Wijn-
gaarden-Crers P, van der Gaag RJ. Treatment seeking adults w ith autism or
ADHD a nd co-morbid substance use disorder: preva lence, risk factors and f unc-
tional disabi lity. Drug Alcohol Depend. 2 009;107:4 4–50 .
20. Kronenberg LM, Goossens PJ J, van Busschah J, va n Achterberg T, van den
Brinck W. Coping styles in substance use disorders (SUD) patients with and
without co-occurring attention deficit / hyperactivit y disorders (A DHD) or
autism spectr um disorder (ASD). BMC Psychiatry. 2015;15:159.
21. L alanne L, Weiner L, Trojak B, Berna F, Berschy G. Substance-use disorder in
high-function ing autism: cl inical and neurocog nitive insights from t wo case
reports. BMC Psychiatry. 2015;15:149.
22. Kronenberg L M, Slager-Visscher K, van Achterberg T, van den Brinck W.
Everyd ay life consequences of substance use in adults pat ients with a substance
use disorder (SUD) and co-occurring at tention deficit /hyperactivity disorder or
autism spectr um disorder (ASD): a patient ’s perspective. BMC Psychiatry.
2014 ;14 :2 64 .
23. Stoddart KP, Bruke L , King R. Aspe rger Syndrome in Adulthood . A Comprehensiv e
Guide for Clinicians. New York, NY: W.W. Norton & Compa ny; 2012.
24. Brorson HH, Ajo A rnevik E, Rand-Hendriksen K, Duckert F. Drop-out f rom
addict ion treatment: a s ystematic rev iew of risk factors. Clin Psychol Rev.
2013; 33:1010 –1024 .
25. Kronenberg LM, Goossens PJJ, van Etten DM, va n Achterberg T, van den
Brinc k W. Need for care a nd life satisf action in adult s with and with out attention

Helverschou et al 9
deficit hy peractiv ity disorder (A DHD) or aut ism spectrum disorders (ASD).
Perspec Psych Care. 2015;51:4–15.
26. S pain D, Sin J, Chalder T, Murphy D, Happé F. Cognit ive behaviour therap y for
adults w ith autism spec tru m disorders and psychiatric co-morbidity: a revie w.
Res Auti sm Spect Disord. 2 015;9 :1151–1162.
27. Vasa RA, Car roll L M, Nozzoli llo A A, et al. A systematic review of t reatments
for anx iety in youth w ith autism spec tru m disorders. J Autism Dev D isord.
2014;44:3215–32 29.
2 8. Wood JJ, Eh renreich-May J, A llessand ri M, et al . Cognitive b ehavioura l therapy
for early adolescents with autism sp ectr um disorders and clinica l anxiet y: a
radomized, controlled trial. Behav er. 2015;4 6:7–19.
29. White S, Ollendick T, Albano AM, et al. Randomiz ed controlled t rial: multi-
modal a nxiety and social skill intervention for adolescents with aut ism spectru m
disorder. J Autism D ev Disord. 2013;43:382–394.
30. Helverschou SB, Utgaard K, Wandaas PC. e c hal lenges of applying and
assessing cog nitive behav ioura l therapy for individua ls on the autism spectrum
in a clinical setting: a case study series. Good Autism P ractice. 20 13;14:
117–127.
31. Baron-Cohen S, W heelwright S, Skinner R, Martin J, Clubley E. e autism-
spect rum quotient (AQ ): evidence from A sperger syndrome/high-funct ioning
autism, males and females, scientists and mathematicians. J Autism Dev Disord.
2001;31:5 –17.
32. Wechsler D, Nyman H, Nordvi k H. WAIS-I II: Wechsler Adult Intelligence Scale:
Manual. Norsk Versjon (Norwegian Version). Stockholm, Sweden: Psykologiför-
laget; 2003.
33. Ørbeck B, Sundet KS. WASI Norsk Versjon, Manualsupplement (Norwegian Ver-
sion of WASI). Stockholm, Sweden: Harcourt Assessment; 20 07.
34. Bosnes O. Norsk versjon av (Norweg ian version of ) Wechsler A bbrev iated Scale
of Intell igence: Hvor godt er sa msva ret mel lom WASI og norsk versjon av (How
well correlate WASI and Norwegia n version of Wechsler Adult Intellig ence
Scale-III?). J Norweg Psych ol Assoc. 2009;46:564 –568.
35. Derogatis LR, Lipman RS, Rickels K, U hlenhuth EH, Covi L. e Hopki ns
Symptom Checkl ist (HSCL): a measu re of primary symptom dimensions. In:
Pichot P, Olivier-Mart in R, eds. Psychological Measurements in Psychopharmacol-
ogy. Vol 7. Oxford, UK : S. Karger; 1974:79–110.
36. American Psychiatric Associat ion. Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Washington, DC: America n Psych iatr ic Association; 1994.
37. Berman A H, Palmstierna T, Kallmen H, Bergman H. e sel f-report Drug Use
Disorders Identi fication Test-Extended (DUDIT-E): reliabilit y, validity, and
motivationa l Index. J Su bst Abuse Treat. 2007;32:357–369.
3 8. B ergman H, K allmen H. A lcohol use among S wedes and a psyc hometric eva luation
of the Alcohol Use Disorders Identification Test. Alcohol Alcohol. 2002;37:245–251.
39. Durbeej N, Berma n AH, Gumpert C, Palmstier na T, Kristians son M, A lm C.
Validation of the Alcohol Use Disorders Identification Test and t he Drug Use
Disorders Identi fication Test in a Swedish sample of suspected offenders wit h
signs of me ntal health p roblems results f rom the mental d isorder, substa nce abuse
and crime study. J Subst Abuse Treat. 2010;39:364–377.
40. Hildebrand M. e psychometric properties of the Dr ug Use Identification Test
(DUDI T): a rev iew of recent resea rch. J Su bst Abuse Treatment. 2015;53:52–59.
41. Endicott J, Spitzer R L, Fleiss JL, Cohen J. e globa l asse ssment sc ale: a proce-
dure for measuring overall severity of psychiatric distu rbance. Arch Gen Psychia-
try. 1976;33:766–771.
42. Aas IHM. Global Assessment of Func tioni ng (GAF). Properties and frontier of
current knowledge. Ann Gen Psychiatry. 2010;9:20.
43. Forsberg L, Berman A H, Kallmén H, Hermansson U, Helga son AR . A test of
the validit y of the mot ivational interv iewing treatment integrit y code. Cognitive
Behav er. 2008;37:183–191.
44. Ma rshall GN, Hay s RD. e Patient Sat isfaction Ques tionnaire Short Fo rm (PSQ-
18) (Report No. P-7865). Sa nta Monica, CA: R and Cor porat ion; 1994.
45. Wood JJ, Drahota A, Sze K, Har K, Chiu A, Langer DA. Cognitive behavioral
therapy for anx iety in chi ldren w ith autism spec tru m disorders: a radomized,
controlled trial. J Child Psychol Psych. 2009;50:224–234.
46. Helverschou SB, Rasmussen K , Steindal K, S øndanaa E, Nilsson B, Nøttestad
JA. Offending profiles of indiv iduals with ASD: a study of al l individua ls wit h
ASD exa mined by the ex pert forensic psychiatric serv ice in Nor way between
200 0 and 2010. Autism. 2015;19:850–858.
47. Sondenaa E , Helverschou SB, Steindal K, R asmussen K, Ni lson B, Nottest ad JA.
Violence an d sexual off ending behav ior in people w ith autism spec trum dis order who
have undergone a psychiatric forensic examination. Ps ychol Rep. 2014;115:32 –43.
48. March JS. e f uture of psychotherapy for menta lly ill children and adolescents.
J Child Psychol Psych. 20 09;50:170–179.
49. Pal mquist E, Clae son AS, Neely G, St enberg B, Nordin S . Overlap in pre valence
between various t ype s of envi ronmental intolerance. Int J Hyg Environ Health.
2014 ;2 17:42 7–434.

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