Autism and Addiction: Risks, Protective Factors, and Treatment Considerations
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Autism spectrum disorder (ASD) is a widely stigmatized and misunderstood neurotype. Often, people assume that autistic people cannot develop addictions or substance use disorders (SUD).
However, several autistic people do experience these disorders, and they may face specific challenges when seeking treatment.
A note about language: This document intentionally uses identity-first language (e.g. “autistic”) rather than person-first language (e.g. “person with autism”) to respect the preferences of the broader autism community. However, we also recognize that some people with autism do prefer person-first language for themselves, and we respect the validity of their choice as well. Occasionally, we also use the word “allistic” to refer to non-autistic people.
What is Autism Spectrum Disorder?
ASD is a neurodevelopmental disability. Autistic individuals may exhibit a range of specific traits. While allistic people may also experience these traits, autistic people experience them more consistently and intensely. These traits include:
social and communication challenges (e.g. difficulty grasping social “rules”)
sensory differences (experiencing sensory information more or less intensely than allistic peers)
repetitive behaviors (e.g. watching the same television shows or eating the same foods)
self-stimulatory (“stimming”) behaviors (e.g. fidgeting, rocking, hand-flapping, repeating words and phrases [echolalia], and several others)
learning differences (including “giftedness,” learning disabilities, and intellectual disabilities)
focused and specific interests (“special interests”)
intense need for routine and predictability
Each autistic person has different strengths, difficulties, and accommodation needs. For example, one autistic person may have strong verbal skills but require sensory accommodations such as headphones. Another autistic person may rarely need sensory accommodations, but they may be nonverbal and use an augmentative and alternative communication device (AAC).
Autism and Addiction
Research on autism and addiction shows mixed results. There are several studies on how autism affects addiction risk. Some indicate that autistic people have a lower risk of addiction than their allistic peers. Others show that autistic people actually experience a higher risk of substance use disorders.
These mixed results may occur for several reasons. For example, in recent years, autism diagnoses have increased significantly. Underdiagnosed demographics, such as women, people of color, and high-masking individuals, have begun seeking diagnosis at higher rates. These demographics have historically been left out of autism studies, and we may see differing numbers as we gain a more accurate view of the autistic population.
Furthermore, mixed results may occur because autistic traits can either increase or decrease a person’s addiction risk. A trait that increases one person’s risk may serve as a protective factor for another person.
For instance, two autistic people may both experience social anxiety. One person may self-medicate with alcohol, which will increase their risk of addiction. Another may avoid social situations altogether, which may prevent them from being exposed to harmful substances.
Protective Factors against Addiction
Some autistic traits may protect those who experience them from addiction and substance abuse.
Sensory Avoidant Behaviors
Autistic individuals have specific sensory needs. Many experience sensory processing disorder (SPD), which impacts how the brain receives sensory information.
Some sensory issues, particularly sensory avoidance, may serve as a protective factor against addiction. For example, some autistic people may not enjoy how drugs and alcohol make them feel, and they might avoid these substances as a result.
Sensory-avoidant people may also avoid the types of places, such as bars and clubs, that are most likely to have drugs and alcohol available. The sights, sounds, and smells within these environments may cause distress, so many autistic people seek quieter environments where these substances are more rare.
Repetition and Routine
Autistic people often need repetition and routine. Deviation from routine can cause discomfort or even severe distress. If drugs and alcohol are not a part of an autistic person’s routine, they might not seek substances.
Need for Downtime
People of all neurotypes may need time to themselves, but autistic people may need more than most others. This time allows them to decompress after socialization and release the expectation to mask autistic traits. Much like sensory avoidance, this need for downtime causes a large number of people to avoid places where drugs and alcohol may be present.
Autism and Addiction Risk Factors
Certain autistic traits may also increase a person’s risk of experiencing addiction. Furthermore, societal issues such as discrimination can also contribute to substance abuse.
Social Anxiety and Masking May Link Autism and Drug Use
One systematic review indicates that up to 50% of autistic individuals experience social anxiety, a debilitating fear of being judged. In many cases, people with social anxiety drink alcohol for temporary symptom relief. Over time, this self-medication may result in alcohol use disorder.
Certain social pressures can add to this problem. For instance, a large number of autistic people use “masking” behaviors to hide their autistic traits. Examples of masking include:
suppressing the need to stim
forcing oneself to make eye contact even when it causes discomfort
eating foods that don’t match sensory needs to avoid appearing “rude”
feigning interest in “typical” subjects while hiding enthusiasm for true interests
intentionally altering tone and facial expressions to appear more “typical”
participating in social norms without agreeing with or understanding them
Repetition and Routine May Complicate Addiction in Autistic Individuals
While repetition and routine can protect some autistic people from addiction, it may increase the risk for others. If one’s routine involves consuming substances, the autistic need for repetition may combine with their physical dependence on those substances, making it especially difficult to quit.
Autism and Addiction May Overlap with Attention Deficit Hyperactivity Disorder
Frontiers in Psychiatry states that up to 70% of autistic people also have attention deficit hyperactivity disorder (ADHD). People with ADHD are significantly more likely to experience addiction than neurotypical peers.
Factors such as reward-seeking behavior, impulsivity, and difficulty obtaining necessary medication can contribute to this risk.
Sensory Processing Issues Connect Autism and Substance Abuse
While some sensory avoidant behaviors may provide protection against substance abuse, others may increase the risk. For example, a person might drink alcohol at a party to avoid thinking about bright lights or loud noises.
Some sensory-seeking behaviors may also contribute. Certain drugs, particularly party drugs, heighten the senses, and some autistic people may seek those substances for that reason.
Autistic People Experience Societal Discrimination
Discrimination may also create a link between autism and addiction. Discrimination against autistic people includes the expectation of masking, dismissal of those who cannot mask, denial of accommodations, harassment and bullying, and several others.
Due to discrimination and other societal factors, many autistic people face unemployment. In fact, multiple sources claim that up to 85% of autistic people are unemployed. This number may not be entirely correct, as it is impossible to tell how many employed, high-masking autistic people remain undiagnosed. It is also important to note that several sources citing the “85%” number are not neurodiversity-affirming, and that other sources provide much lower numbers. Nevertheless, unemployment does impact a significant amount of people on the spectrum, and unemployment is associated with a higher risk of substance abuse.
Autistic People Experience Infantilization
Many people, including mental health experts and medical professionals, infantilize autistic individuals. This infantilization is not always intentional, but it does impact their understanding the link between autism and addiction.
People often view addiction as a disorder that only adults experience, in spite of the fact that children and adolescents may also experience addiction. Further, people often see autism as a condition that only exists in children, in spite of the fact that autism is a lifelong neurotype.
As a result of these misguided beliefs, there is limited support for autistic individuals with addiction. Loved ones and healthcare providers may not immediately notice when an autistic person displays signs of substance abuse, or they may conclude that these signs have a different cause.
This dismissal may delay or even stop the person from receiving the substance abuse care they need.
Treatment Options for Autistic People with Substance Use Disorders
Autistic people may seek several treatment options for substance abuse recovery. Regardless of one’s neurotype, addiction treatment generally works best when it is tailored to the person’s needs.
Autistic people and their loved ones should consider their specific needs and circumstances when pursuing addiction care.
Levels of Care
The American Society of Addiction Medicine defines certain levels of care. These levels range in their intensiveness. Often, people begin with a more intensive level of care and then gradually move through less intensive levels.
However, a person’s ideal level of care depends on the severity of their addiction and the amount of support they have at home.
Autistic individuals should consider the fact that higher intensive levels of care tend to offer more routine and structure than lower intensive levels. However, lower intensive levels of care allow clients to live at home during treatment, which may provide a sense of comfort and familiarity if you or your loved one struggle with change. Levels of care include:
medication-assisted treatment (MAT): MAT uses medications, such as opioid replacement therapy, to alleviate withdrawal symptoms. It can be used on both an inpatient and outpatient basis.
inpatient programs: inpatient treatment generally takes place in a clinical setting for a period of up to 90 days.
residential programs: similar to inpatient programs, residential programs provide food and housing during treatment. While still highly structured, residential programs are less clinical than inpatient programs and also tend to last longer.
partial hospitalization programs (PHP): PHP is the most intensive type of outpatient treatment for addiction. Clients receive treatment for at least 20 hours per week.
intensive outpatient programs (IOP): intensive outpatient programs offer care for nine to 20 hours per week.
outpatient programs: the least intensive outpatient programs offer care for fewer than nine hours per week. Many people choose an outpatient program as a form of aftercare once they have completed a more intensive type of treatment.
Therapy Modalities for Neurodiversity and Addiction Recovery
Modalities are approaches to therapy, or methods that a practitioner may use with their clients. Many therapists use a mixture of modalities in their practices. Often, addiction treatment centers list the types of therapies that they use on their website, but you may also contact specific programs to ask about their approach.
If modality matters to you, or if therapy is a special interest, consider which types might best meet your needs. For example, motivational interviewing may help you find reasons for recovery, while trauma-informed therapy can help you process difficult circumstances.
Other Considerations for Autism and Substance Abuse
In addition to therapy modalities and levels of care, you might consider several other factors relating to addiction treatment for autistic people.
Case Management and Individualized Care
Several addiction treatment programs offer case management services. With these services, a healthcare professional or team of professionals work with the individual to plan their care. They may check in with the person on a regular basis to make adjustments as needed.
This process may prove helpful for autistic clients seeking addiction services. The most effective treatment for allistic people may not always work for autistic people, and vice versa. Working with a case manager can help you individualize your or your loved one’s care plan to maximize effectiveness.
Telemedicine
If you or your loved one might benefit from low-intensive treatment, telemedicine may provide the right fit. With telemedicine, a client can receive therapy or other healthcare services via video call or other digital means. This option may work well for those whose routines and sensory needs are best met at home.
Accommodations for Autism and Substance Abuse
If possible, look for addiction care programs that can easily provide accommodations. Possible accommodations to ask for include:
an emphasis on individual therapy with less focus on group therapy
longer rest periods
not being required to speak during group therapy
filters for harsh lights in personal living spaces
allowing headphones
limiting non-concrete language during therapy sessions
notes or handouts of topics covered during therapy sessions
advance warnings ahead of changes
sensory-safe foods
sensory-friendly recreation options
allowing fidget tools during therapy sessions
alternative choices for group activities that may contribute to burnout, meltdown, or shutdown
alternative bilateral stimulation options during EMDR (see “A Note on EMDR Therapy” below)
an additional allotment for packing personal items, to allow comfort items or sensory tools
You might speak to providers upfront about your need for accommodations before committing to a specific program.
Wraparound Services
Some treatment programs offer wraparound services, which are services that address additional client needs. Some examples of wraparound services include housing help, legal counsel, job training, medical care, and many others.
Many autistic people face challenges in these areas. If you require housing help or another form of assistance, you might seek an addiction program that offers such services or can provide a referral.
Aftercare
In addiction treatment, aftercare is a long-term treatment that a person may pursue after attending a substance abuse program. Aftercare services are usually low-intensive options, such as seeing a therapist once a week or checking in with a recovery coach.
Some addiction programs offer aftercare as a part of their services, but you may also seek aftercare from other sources.
Addiction aftercare can help you maintain a recovery routine as you regain a post-treatment sense of structure.
Recovery Housing
Recovery housing, also called sober living housing, may benefit autistic people who need continued structure and support after addiction treatment.
Recovery housing spaces are living environments, such as shared homes or apartments, for people healing from substance abuse. These environments are free from drugs and alcohol.
They also generally have well-established rules and routines, which may include doing chores and attending meetings. Autistic residents may enjoy the structure of these environments, as well as knowing exactly what is expected of them.
A Note on EMDR Therapy
Eye movement desensitization and reprocessing therapy (EMDR) is a trauma therapy used by many addiction treatment programs. In this modality, the client processes their trauma while performing a type of bilateral stimulation.
The most common form of stimulation in this modality is eye movement. Generally, the client tracks a light with their eyes as the light moves from side to side. Many clients, including allistic clients, note that this light is extremely bright. It may cause sensory distress for autistic participants.
If you believe you would benefit from EMDR but have a sensitivity to light, ask your therapist for alternative options. Other forms of bilateral stimulation include following a dot on a computer screen and tapping on either side of the body.
With the right bilateral movement, this therapy might combine the effectiveness of EMDR with the calming benefits of stimming.
What Practitioners Should Know about Addiction in Autistic Individuals
When working with autistic clients, addiction care providers should keep certain things in mind. These considerations can increase the client’s chances of success during treatment.
Use Preferred Language
In the mental health profession, practitioners are often taught to use person-first language (e.g. “person with autism”) and avoid identity-first language (e.g. “autistic person”). However, it is important to respect the language preferences of those who belong to the community you are speaking about.
Multiple studies, surveys, and polls find that autistic adults prefer identity-first language. For example, a study on language preference found that 87% of surveyed autistic adults preferred an identity-first approach. Still, some do prefer person-first terminology, which means that it is not guaranteed that your clients will prefer the word “autistic.”
When treating an autistic client and speaking about their identity, use the language that the client prefers.
Don’t Assume Willful Noncompliance
Noncompliance is a common issue among people receiving mental health care. Noncompliance may be accidental, such as when a person forgets to take medication, or intentional, such as when a person refuses to participate in therapy.
If an autistic client appears noncompliant, do not assume that their noncompliance is intentional or willful. In some cases, what looks like noncompliance may actually be an uncontrollable or necessary autistic behavior.
For example, a client who does not speak may be experiencing a nonverbal episode rather than giving you the “silent treatment.” A client who does not appear at therapy may be recovering from sensory overload.
Avoid Infantilizing Autistic Clients
If your client is an adult, they should be treated as such. Always speak to your clients in an age-appropriate manner.
Offer Accommodations
Accommodations can help make your client’s addiction care experience as effective as possible. When the client’s needs are met, they can focus on the healing journey and avoid distractions.
However, some autistic people, particularly late-diagnosed autistic people, may not know which accommodations can be made available to them. As a practitioner, you might explain some options upfront. Some accommodation possibilities include:
respecting the client’s mode of communication, such as an AAC device or gestalt language processing
An American Sign Language (ASL) interpreter for clients who sign when nonverbal
not requiring autistic clients to speak in group therapy
allowing autistic clients alone time if necessary
prioritizing individual rather than group therapy
sensory-friendly spaces
sensory-friendly food options
advance notice prior to any schedule changes, such as group outings
using concrete rather than abstract language during therapy sessions
allowing personal comfort items, such as a weighted blanket, during sessions or in the client’s room
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Sources:
Autism in Adulthood – Understanding Stigma in Autism: A Narrative Review and Theoretical Model
Frontiers in Psychiatry – Attention-Deficit/Hyperactivity Disorder in Relation to Addictive Behaviors: A Moderated-Mediation Analysis of Personality-Risk Factors and Sex
Healthcare – Unemployment and Substance Use: an Updated Review of Studies from North America and Europe
Job Accommodation Network – Autism Spectrum
National Autistic Society – Addiction
Sage Journals – Preferences for Identity-First Versus Person-First Language in a US Sample of Autism Stakeholder